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UNITED STATES OF AMERICA. 



Differential Diagnosis 



A MANUAL OF THE 



COMPARATIVE SEMEIOLOGY 



OF THE 



MORE IMPORTANT DISEASES. 

/ 

By F. de HAVILLAND HALL, M. D., 



ASSISTANT PHYSICIAN TO THE WESTMINSTER HOSPITAL, LONDON, 



f 



THIRD AMERICAN EDITION. 
Tlioronglily Revised, and. GJ-reatly Enlarged, 



EDITED BY FRANK WOODBURY, M. D., 

PROFESSOR OF THERAPEUTICS AND MATERIA MEDICA AND OF CLINICAL MEDICINE IN THE 
MEDICO-CHIRURGICAL COLLEGE; ETC. 



PHILADELPHIA : 

D. G. BRINTON, 115 SOUTH SEVENTH STREET. 

1887. 



V OCT 8 I8ff£ 



Entered according to Act of Congress, in the year 1887, by 

D. G. BRINTON, 

in the Office of the Librarian of Congress, in Washington, D. C. 

All rights reserved. 



PRESS OP 

INQUIRER PRINTING CO. 

LANCASTER, PA. 



PUBLISHER'S NOTE 



THIRD AMERICAN EDITION 



The present work is founded upon Dr. F. De Havilland Hall's 
Synopsis of the Diseases of the Larynx, Lungs y and Heart. The plan 
adopted by Dr. Hall has, however, been extended to embrace all the 
more frequent and important diseases. 

In the preface to the first American edition the editor stated that he 
had held especially in view (i) the early and often overlooked signs 
of the presence of disease ; (2) the collection of whatever symptoms : 
are alleged on good authority to be pathognomonic of pathological 
conditions ; (3) any peculiar features which diseases have been found 
to present in this country. " Preference has been given to American 
over European authorities, as every year adds confirmation to the 
opinion, now widely received, that diseased conditions assume very 
different aspects under different climatic and sociological surround- 
ings." 

In presenting this third edition, the publisher was fortunate enough, 
as in the second edition, to complete an arrangement with Dr. Frank 
Woodbury to give it a thorough revision, and to add to it what was 
lacking to make it a complete work within the limits which it aims to 
cover. 



INTRODUCTORY. 



In the nomenclature commonly adopted by the best authorities, dis- 
eases are divided into two great classes — General and Local. General 
diseases may^be said to comprehend those which affect and pervade 
the whole system, and in which any local disorder may be regarded 
as either an accidental complication or sequel; while local diseases are 
those in which certain organs are especially attacked, and in which the 
involvement of any other part of the body is considered as consecu- 
tive to, or the result of, the primary lesion. 

This classification, having much to recommend it, from a clinical 
standpoint, is the one most practically useful to the physician. The 
first question he should put to himself on examining a patient is, Have 
we here a general or a local disease? He reaches the answer by ex- 
cluding those organs whose form and functions present nothing abnor- 
mal, and by distinguishing, among such as are implicated, those which 
indicate primary and essential lesions, from those which are affected 
accidentally or secondarily. Where no primary lesions are discover- 
able, he may conclude that he has to do with a general disease. 

For the purpose of diagnosis, General Diseases may be conveniently 
divided into the two morbid groups of (i) Fevers and (2) Diseases of 
the Blood. These also are each divisible into two or more classes, 
marked by a few leading and prominent symptoms, which are the 
guides to the diagnostician. Thus, 

The Essential Fevers are usually acute in their course, and either 
characterized by an eruption of a well-defined character (the Exanthe- 
mata); or by a recurrent marked diminution (remission) or periodical 
total cessation (intermission) of the symptoms (Periodic fevers); or 

(v) ' 



VI INTRODUCTORY. 

else by a persistent pyretic course not manifesting either of these phe- 
nomena (Continued fevers). 

Blood Changes are rarely acute, and are either constitutional (the 
Dyscrasiae) ; or else characterized by definite organic lesions (Rheu- 
matism, Gout); or by a physical and generally recognizable change in 
the blood itself (Anaemia, Leukaemia, Scurvy and Purpura). 

Local Diseases are more conveniently classified with reference to the 
physiological than the anatomical divisions of the body. The func- 
tions of life are carried on by the Nervous, Muscular and Osseous 
systems, and the various organs forming the Respiratory, Circulatory, 
Digestive and Urino-genital apparatus; and the impairments of each 
of these form classes of diseases which are broadly discriminated by 
signs easy of recognition. The niceties of diagnosis are needed rather 
to distinguish between the varied diseases peculiar to each of these 
systems than to locate the disturbance in one or the other of them. 



CONTENTS 



Introductory ■ 

PART I. 
GENERAL DISEASES. 



CHAPTER I. 

THE FEVERS. 



PAGE 

-The Febrile State 17 

Inflammatory, or Symptomatic and Essential Fever 22 

The Exanthematous or Eruptive Fevers . • 23 

Typhoid and Typhus Fevers 31 

Typhoid and Malarial Fevers 37 

The Typhoid State , 41 

Malarial Fevers 42 

Cerebro-spinal Fever 47 

Acute Tubercular Meningitis 49 

Yellow Fever r . 53 

Relapsing Fever . . . . ; , . . 56 

CHAPTER II. 

DISEASES OF THE BLOOD. 

The Dyscrasiae 59 

The Arthritric, Dartrous, or Rheumic Dyscrasia 59 

The Scrofulous, or Strumous Dyscrasia 61 

The Syphilitic Dyscrasia 62 

The Tuberculous Dyscrasia 63 

Ehrlich's Method for Detecting Tubercle Bacilli 65 

•Rheumatism 65 

Chronic Rheumatism 67 

Gout 72 

Rheumatoid Arthritis 73 

Pernicious Anaemia and Leukaemia '. . . . 73 

Remarks on the Germ Theory 75 

Pyaemia and Septicaemia 78 

(vii) 



CONTENTS. 



PART II. 
LOCAL DISEASES. 



CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM. 

Nervous Symptoms 82 

Cerebral Congestion and Cerebral Anaemia 83 

The Symptoms of Cerebral Apoplexy Contrasted with those of Drunkenness, Narcotic 

Poisoning, Uraemia, Hysteria, Syncope, and Asphyxia 84 

Reflex Hemiplegia • 85 

Cerebral Hemorrhage vs. Thrombosis and Embolism 86 

Acute Cerebral Inflammations 87 

The Ophthalmoscope in Nervous Disorders 89 

Headache 91 

Chronic Cerebral Disorders 93 

Hypertrophy of Brain and Hydrocephalus 93 

Brain Tumors, Softening, Abscess, Meningitis, and Thrombosis 94 

Cerebral Sclerosis vs. Defective Development of Intelligence 94 

Localization of Brain Disease 95 

Lesions of Cerebral Cortex (with Diagram) 95 

Disease of Brain Centres other than Cortical 98 

Infantile Cerebral Paralysis 100 

Spinal Diseases , 101 

Tabular View of Spinal Paralysis 103 

Myelitis, Meningitis, and Congestion Compared , 106 

Chronic Spinal Disorders 107 

Degenerative Diseases 108 

Tendon Reflex 112 

Cerebro-spinal Sclerosis, Paralysis Agitans, and Locomotor Ataxia 114 

Paraplegia, from Reflex Irritation and Myelitis 115 

Pseudo-hypertrophic Paralysis 1 16 

Paralysis, from Lead Poisoning and Hysteria . 118 

General Paralysis of the Insane 119 

General Paralysis and Locomotor Ataxia 120 

General Paralysis and Syphilitic Paralysis 123 

Spinal Irritation and Spinal Weakness 124 

Neurasthenia ...... 126 

Hysteria 132 

Epilepsy and Hystero-epilepsy 133 

Tetanus, Hysteria, Strychnine Poisoning, Tetany 134 

Neuralgia 13c 



CONTENTS. IX 

PAGE 

Neuralgia and Myalgia 136 

Cerebral Abscess vs. Cerebral Neuralgia 137 

Multiple Neuritis 138 

Insanity 140 

Mania and Melancholia 142 

Classification of Mental Diseases 143 

CHAPTER II. 

DISEASES OF THE RESPIRATORY APPARATUS. 

Symptoms of Laryngeal Diseases 145 

Diagnostic Table of Acute Laryngitis; Chronic Laryngitis; Syphilitic Laryngitis; 

Tubercular Laryngitis 146 

Perichondritis ; Benign Growths ; Malignant Growths ; Neuroses of the Larynx . . . 148 

Croup and Diphtheria 151 

Spasmodic Croup 15 1 

Inflammatory Croup ; 151 

Membranous Croup 152 

Diphtheria 152 

Tonsillitis, Catarrhal and Parenchymatous 154 

The Regions of the Chest 155 

Normal Differences between the two Sides of the Chest 156 

Methods of Physical Examination 156 

Normal Respiratory Sounds . 157 

Normal Voice Sounds 158 

Abnormal Percussion Sounds 159 

Abnormal Respiratory Sounds 160 

Amphoric Sound . 162 

Abnormal Voice Sounds . 163 

General Rules for Diagnosis t . 164 

The Forms of Phthisis (Catarrhal, Fibroid, Tubercular) 166 

The Diagnosis of Incipient Phthisis 168 

Diagnosis between Incipient* Phthisis and Bronchitis 170 

Clinical History of Phthisis . 172 

Acute Phthisis (Acute Miliary Tuberculosis) 173 

Syphilitic Phthisis 175 

Bronchitis, Acute and Chronic 176 

Capillary Bronchitis compared with Pneumonia • . .178 

Pneumonia and Pleurisy 179 

Pleurisy and Hydrothorax 181 

Pleurisy with Effusion and Pneumonia with Consolidation Compared 184 

Diagnosis between Pneumonia and Pulmonary Apoplexy t . 184 

Pulmonary Thrombosis .' 186 

Asthma 186 



X CONTENTS. 

PAGE 

Pneumothorax and Pneumo-hydrothorax 187 

Emphysema, Vesicular and Interlobular 189 

Cancer of the Lung 191 

CHAPTER III. 

DISEASES OE THE CIRCULATORY APPARATUS. 

The Precordial Regions ^ 192 

The Area of Cardiac Dulness 193 

Normal Sounds arid Impulse of Heart 194 

Endocardial Murmurs 195 

General Rules for the Diagnosis of Heart Disease 196 

Constitutional Symptoms of Heart Disease 196 

Clubbing of the Fingers 197 

Differential Signs between Anemic and Organic Murmurs 198 

Pain at and near the Heart .... 198 

Aphorisms Regarding Angina Pectoris 199 

Differential Signs of Aortic Obstruction and Aortic Incompetency 200 

Differential Signs between Mitral Obstruction and Mitral Incompetency 202 

Differential Signs between Pulmonary Obstruction and Tricuspid Regurgitation . . . 203 

Pericarditis 204 

Diagnosis between Acute Endocardial and Exocardial Sounds 206 

Differential Signs of Cardiac Dilatation and Pericarditis with Effusion 206 

Differential Signs of Simple Hypertrophy, Hypertrophy with Dilatation, and Simple 

Dilatation 207 

Fatty Degeneration of the Heart 208 

CHAPTER IV. 

DISEASES OF THE DIGESTIVE SYSTEM. 

Principal Symptoms 211 

The Tongue 211 

The Appetite. . 213 

Acidity (1) from Fermentation; (2) from Hyper-secretion 213 

Gastralgia 214 

Flatulence and Eructation 216 

Vertigo, (1) Stomachal; (2) Cerebral 216 

Vomiting, (1) Stomachal; (2) Cerebral 217 

Comparison of Atonic Dyspepsia, Chronic Gastritis, Gastric Ulcer and Gastric Cancer. 219 

Indigestion and Dyspepsia 221 

Abdominal Phthisis 223 

Obstruction of the Bowels, Enteritis and Colitis 223 

Method of Examination of the Liver 227 

Significance of Pain in the Liver 227 



CONTENTS. . XI 

PAGE 

Significance of Jaundice 229 

Jaundice with Obstruction 229 

Jaundice without Obstruction 230 

Diseases Characterized by Enlargement with Smooth Surface 231 

Enlargement with Uneven Surface 233 

With Diminution of the Organ 233 

Hepatic Abscess 233 

Internal Parasites , 234 

Tape-worm 234 

Hydatids 234 

Round Worms 234 

Thread Worms 234 

Trichinosis , 235 

CHAPTER V. 

DISEASES OF THE URINARY ORGANS. 

The Early Signs of Bright's Disease 237 

Comparative Diagnosis of the Different Forms of Bright's Disease (Acute Parenchyma- 
tous Nephritis, Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Con- 
traction of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albuminoid or Amy- 
loid Ronal Degeneration, Parenchymatous Renal Degeneration) 240 

Diabetes Mellitus and Glycosuria 243 

Diabetes Insipidus and Hydruria 245 

Bile in the Urine 246 

On Testing the Urine . 246 

Urinary Calculi 249 



HALL'S 

DIFFERENTIAL DIAGNOSIS. 



PART I 



GENERAL DISEASES. 



CHAPTER I. 
THE FEVERS. 

Contents. — The Febrile State — Inflammatory, or Symptomatic, and 
Essential Fevers — The Exanthemaious or Eruptive Fevers — Typhoid 
and Typhus Fevers — Typhoid and Malarial Fevers — The Typhoid 
State — Malarial Fevers — Cerebrospinal Meningitis — Acute Tubercu- 
lar Meningitis — Yellow Fever — Relapsing Fever. 

THE FEBRILE STATE. 

The most common of all forms of disease is that which is presented 
by the Febrile State (Pyrexia). The chief objective symptoms which 
it offers are found in 

I. The elevated temperature. 
II. The pulse. 

III. The tongue and throat. 

IV. The urine. 

V. The state of the skin. 

I. The rise of temperature is one of the most prominent of the 
phenomena in fevers, and by many is regarded as the essential feature 
of the febrile condition; yet its correct appreciation was never under- 
stood previous to the labors of Wunderlich. Now, the clinical ther- 
mometer is considered as necessary to the practitioner as the lancet 
used to be. For diagnostic purposes, a correct thermometer is now 
indispensable. It should be self-registering, and should occasionally 
be compared with a standard thermometer, to insure correctness. The 
instrument in general use is of glass, with mercurial index. The ther- 

* (17) 



I 8 DIFFERENTIAL DIAGNOSIS. 

mometer should be kept scrupulously clean, but it must never be 
washed with hot water, or it will be broken. 

In using the clinical thermometer, Dr. Sydney Ringer, of London, 
has laid down the rule that in order to insure correctness in the obser- 
vations, the following conditions must be fulfilled: 

ist. That the patient should be in bed, otherwise the temperature 
of the surface will be much below that of the internal organs. 

2d. That the patient be in bed at least one hour before the observa- 
tions are made, since that time is necessary for the surface of the body 
to regain the heat lost by previous exposure. 

3d. The position of the person examined should be such that the 
anterior and posterior edges of the axilla are relaxed, for otherwise a 
cup-shaped cavity is formed, in which the thermometer moves freely 
without being in contact with its walls. This occurs especially in 
emaciated persons. 

4th. The temperature should be taken twice daily, say at eight in 
the morning and eight in the evening. If but one observation is pos- 
sible, then the evening should be preferred, since the morning temper- 
ature, abnormal though it may be, rises in the evening. 

5th. The thermometer should remain in the axilla at least five 
minutes. 

Although the axilla is generally selected, on account of convenience, 
the temperature is often taken with the thermometer in the rectum or 
vagina, especially in children, and it is believed that such observations 
give more correct indications of the heat of the body than those taken 
on the surface. Many physicians prefer to place the thermometer in 
the mouth. The temperature under the tongue is half a degree higher 
usually than that of the axilla. 

The temperature fluctuations in the various zymotic diseases have 
now been carefully studied by many clinical observers, who have de- 
duced observations which are of great service in diagnosis, as some of 
them are characteristic. 

A pretty constant increase and decrease of temperature exists in 
the several specific fevers, a close observation of which, in accordance 
with the foregoing rules, will often serve as a valuable aid both in di- 
agnosis and in prognosis. Dr. Wunderlich, in his work, gives useful 



FEVERS. 



19 



tables for this purpose, and we subjoin a valuable comparative table of 
the pulse as well as the temperature in seven of the more frequent 
febrile diseases, drawn from English observations. 



COMPARATIVE TABLE OF THE TEMPERATURE AND PULSE IN THE 
LEADING FEBRILE DISEASES. 



Day. 



ISt. 

2d. 

3d- 

4th. 

5th. 

6th. 

7th. 

8th. 

9th. 
10th. 
nth. 
1 2th. 
13th. 
14th. 
15th. 
1 6th. 
17th. 
1 8th. 
19th. 
20th. 
21st, 



Typhus 
Fever. 


Typhoid 
Fever. 


Measles. 


Scarlet 
Fever. 


Febricula. 


Rheumatic 
Fever. 


Pneumonia. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


p. 






102. 


98 






104.2 


144 


103. 


99 






102.8 


123 


104.8 


108 


103. 1 


98 






104. 


148 


I03-7 


103 






102.3 


120 


103.6 


"3| 


103.4 


no 


102.3 


130 


103. 


134 


104. 


105 


101.8 


io 5 


103.6 


122 


103. 


114I 


102.7 


107 


103. 


124 


101.2 


122 


102.6 


99 


102. 


114 


104. 


126 


103.2 


122 


103.2 


104 


100.2 


112 


100.6 


108 


98.4 


99 


102. 


116 


103. 


122 


104.2 


124 


I03-7 


107 


98. 


102 


100. 


106 






103. 


120 


102.8 


122 


103.8 


122 


102. 5 


108 


98. 


98 


100. 


no 






100. 


90 


IOO. 


114 


103. 


"3 


103. 


108 


98. 


80 


99.8 


108 






TOO. 


96 


99. 


94 


102.7 


117 


102.6 


in 






99. 


100 






994 


86 


98. 


7* 


102.4 


119 


103. 


in 






98.6 


104 






IOI. 


104 






102.2 


108 


102.5 


112 






98. 


84 






IOI. 


102 






100.5 


106 


102.2 


108 














102. 


IOO 






100. 


100 


102.4 


109 














100.9 


IOO 






99.4 


98 


101.8 


107 














IOO. 


88 






98.7 


92 


102. 


100 














9 8. 


90 






98.4 


90 


101.4 


100 














99. 


94 






98.2 


*5 


98.8 
101.4 
102.2 

98.8 


98 

105 

100 

98 














102. 
103. 

101. 6 

101. 7 


96 
102 

IOO 

104 







The above table, prepared from a series of observations, by Dr. J. S. 
Warter,* illustrates the normal and average contrasts of pulse and 
temperature in the course of the diseases specified, when their ten- 
dency is to recovery. 

II. The pulse is increased in frequency, and usually diminished in 
force; it may also be either hard, full and bounding, or tense, small and 
contracted. The former condition is more common in active inflam- 
mation of the organs above the diaphragm ; the latter, in many in- 
flammations below the diaphragm and in idiopathic fevers. In fevers 
of a typhoid form, an unusually slow pulse is sometimes encountered, 
and also a pulse with apparently a double beat, the "dicrotic" pulse. 



* St. Bartholomew^ Hospital Reports, vol. ii., p. 78. 



20 DIFFERENTIAL DIAGNOSIS. 

In the later stages the pulse may be soft, gaseous or thready, indicat- 
ing febrile changes in the walls of the vessels and the heart. Irregu- 
larity in the pulse occurs in pericarditis, and is among the early indi- 
cations of brain disorder in young children. It is very common in 
advanced heart disease, but is also met with in functional disorders 
due to indigestion. Intermittent pulse is sometimes met with in typhus 
and other fevers. A slow pulse is often met with in yellow fever, 
dengue, and jaundice. A slow pulse also is apt to follow malarial 
fevers. 

III. The tongue in the beginning of the febrile state is usually whiter 
and drier than usual, and more or less coated with a "fur" or viscid 
covering, from the more rapid evaporation of the watery secretions. 
Later, in the progress of severe fever, the tongue becomes dry, and 
the desiccated mucus and epithelium form a brownish or blackish 
crust, while the papillae shrink, so that on this crust becoming de- 
tached, the surface of the organ looks glazed and smooth. The 
peculiar appearance of the tongue in certain diseases will be described 
in connection with these diseases. 

IV. The urine in fever is scanty and high colored. Its alteration 
from the healthy average composition is chiefly in the much larger 
quantity of urea and urates which it contains, and the diminution of 
its chlorides. According to the researches of Dr. J. Burdon Sander- 
son, in the early stage of fever a patient excretes about three times as 
much urea as he would do on the same diet if he were in health, the 
difference between the healthy and the fevered body consisting chiefly 
in this, that whereas the former discharges a quantity of nitrogen 
equal to that taken in, the latter wastes the store of nitrogen contained 
in its own tissues. That this disorder of nutrition is an essential con- 
stituent of the febrile process is indicated by the fact that it not only 
accompanies the other phenomena of fever during their whole course, 
but precedes the earliest symptoms, and follows the latest. That it 
anticipates the beginning of fever, was first demonstrated by Dr. Syd- 
ney Ringer in his investigation of the relation between temperature 
and the discharge of urea, in ague. That the same condition contin- 
ues after the crisis has passed, i. e., the temperature has begun to sink, 
was shown by Dr. Squarey. 



FEVERS. 2 1 

There are various methods of determining the rate of secretion and 
the amount of urea. Its relative excess may be inferred when the 
urine has a deep yellow color, a high specific gravity, and a strong 
urinous odor. If a small quantity of it be allowed to evaporate to a 
mucilaginous consistence, and nitric acid be added, drop by drop, crys- 
tals of nitrate of urea are formed after a few hours. They are of a 
pearly white lustre, and their proportion roughly indicates the quan- 
tity present. When the urea is in great excess, the crystals will form 
on the addition of nitric acid to the urine, without the preliminary 
evaporation, by merely allowing the test-tube to stand for a short time. 
The quantitative determination of urea will be considered under the 
Diseases of the Urinary Organs. 

V. The skin, in common with the other emunctories, has its func- 
tions much influenced by the fever process. Apart from the changes 
in temperature, considered above, there are alterations in the appear- 
ance of the skin, and in the character of its secretions, which accom- 
pany fevers; certain eruptions also appear, that are more or less 
characteristic; such as the small-pox pustule, the chicken-pox vesicle, 
the urticarial wheal, and the scarlatinal dermatitis. The parasitic dis- 
eases of the skin, although they may accidentally be associated with 
pyrexia, exist entirely independently, and the fever bears no causal 
relationship to them. Diphtheria of the cutaneous surface may or 
may not be accompanied by symptoms of constitutional disturbance. 

The skin during fever, has for its typical appearance a color which, 
if not decidedly dull and sallow, is at least less clear than in health ; 
in typhus it may be quite dusky; in bilious remittent and yellow fever 
it becomes jaundiced. In typhoid the surface is more nearly that of 
health, but the cheeks are flushed ; there are also rose-spots on the 
chest and abdomen. In acute rheumatism, and in the third stage of in- 
termittent, the skin is covered by a profuse perspiration, which in the 
former case has a sour smell. Exhausting sweats also occur in pyae- 
mia and phthisis. But the dull-colored, dry and harsh skin is the 
characteristic appearance, and is due to deficient action of the perspir- 
atory and other glands. Certain exhalations of the skin convey con- 
tagion, and some of the eruptive disorders have characteristic odors 
accompanying them, which are exhaled by the skin. 



2 2 DIFFERENTIAL DIAGNOSIS. 

INFLAMMATORY SYMPTOMATIC AND ESSENTIAL 

FEVERS. 

The group of symptoms, collectively known as a fever, often accom- 
panies strictly local maladies and injuries. In such cases it is distin- 
guished as Inflammatory, or Symptomatic. Fever, and it is of the first 
importance to distinguish it from Essential, or Idiopathic, Fever, under 
which general term all true fevers are included. The development of 
this distinction has been one of the most prominent achievements of 
the modern methods of diagnosis. "It is astonishing/' remarks an 
eminent writer, M with the progress of medicine, how many affections 
have been passed over from the domain of fevers to the narrower cir- 
cle of inflammation of individual organs." Hence it is of prime im- 
portance to determine promptly in the beginning of a case whether 
the febrile symptoms are a feature of a local disease, or the com- 
mencement of a general one. 

Inflammatory or Symptomatic Essential or Idiopathic Fever, 

Fever. 

Is usually preceded by some Has no definite antecedent local 
local lesions or symptoms. symptoms. 

Pulse frequent, full and gener- ' Pulse frequent, full or small, but 

ally tense. rarely tense. 'Da Cost.-- 

Is accompanied by marked and Local disturbances van*, and 
definite local disturbance. are not prominent, or but tempo- 

rarily so. 

Course is indefinite, dependent Runs a definite course, with a 
upon the progress of the local strong tendency to spontaneous 
lesion. termination at a given time. 

Anatomical lesions marked, defi- Generally characterized by ob- 
finite and invariable. seme, relatively unimportant, or 

entirely absent anatomical lesions. 

Prognosis mainly depends upon Local manifestations of less im- 
the progress of local lesion. portance in estimating the prog- 

'nosis. 

Dr. William Stokes* divides the local symptoms of essential fever 

* •' Lectures on Fever,** London, 1S74. 



FEVERS. 23 

into three groups: (1) Functional or nervous; (2) those dependent on 
special anatomical changes; (3) those arising from re-active inflam- 
mation. 

Examples of functional symptoms are delirium, carphologia, cough, 
diarrhoea, epigastric tenderness, and the like; of the second group, 
the alterations which occur in the brain, heart, lungs, spleen or intes- 
tinal glands; and of the third, the swelling and infiltration of organs. 
What he calls " the grand rule of diagnosis" in fever is not to apply to 
these local symptoms in essential fever the rules of diagnosis of local dis- 
eases, as this would lead to a false appreciation of the disease, and to 
erroneous treatment. For example, a typhus patient may exhibit the 
marked symptoms of inflammation of the brain; but if he be treated 
with active antiphlogistic treatment, and with ice to the head, and 
leeches, he forthwith sinks and dies. 

Of hardly less importance is the distinction between organic and 
functional (or neurotic) changes in fevers. Delirium, pain, coma, con- 
vulsions, cough, etc., may all appear as phenomena of the evolution of 
the poison which produces a general fever, without signifying any 
definite anatomical lesion. In other words, essential fever produces 
local symptoms without organic change. " It is," remarks the author 
just quoted, " because this proposition has not been sufficiently 
accepted — sufficiently engraved upon the minds of medical men — that 
so much mischief has been done in the erroneous treatment of fever." 

Remarkable cases of inordinate rise of temperature have been 
reported in hysterical subjects. In a young woman who had accident- 
ally received a concussion of the spine, the temperature of the axilla 
reached 122 (Teale). When all possibilities of imposture have been 
excluded, (such as friction of the bulb of the thermometer), these aber- 
rant cases of high temperature will be found to be very few and far 
between. The diagnosis from the essential fevers is readily made by 
attending to the other clinical features of the case in question. 

THE DIAGNOSIS OF THE ESSENTIAL OR ERUPTIVE 
FEVERS (EXANTHEMATA). 
This group includes small-pox, varioloid, scarlet fever, measles, 
roseola, and also those more indefinite forms, varicella and rotheln. 



24 DIFFERENTIAL DIAGNOSIS. 

They have many points of similarity. "They are all characterized by 
a period of incubation, during which the poison lies dormant in the 
system ; by a fever of more or less , intensity preceding the eruption ; 
by an eruption which presents a distinct aspect in each disease, and 
which pursues a definite, clearly defined course, until it, and with it 
the febrile malady, disappears. Moreover, they are all very prone to 
occasion serious sequelae; are all, in the main, disorders of childhood; 
rarely attack the same person twice ; are contagious, and have not as 
yet been brought under specific treatment." (Da Costa.) 

It is of great credit to the practitioner, and often of the utmost util- 
ity to others, for him to make an early diagnosis between these dis- 
eases. This is not always possible to accomplish. But a close 
observer will find several indications which will guide him to a cor- 
rect opinion before the appearance of the rash. Among the principal 
of these is : — 

The condition of the throat. This ' region is affected at a very early 
stage in nearly all cases. In simple scarlatina the very earliest symp- 
tom is a more or less uniform redness of the middle of the soft palate, 
the uvula alone, or the uvula, anterior pillars of the fauces, and ton- 
sils ; never the posterior wall of the pharynx alone. On the other 
hand, in small-pox, the part first affected is the posterior wall of the 
pharynx; while in measles the posterior walls of the fauces and neigh- 
boring parts of the pharynx are always redder than the anterior pillars 
and soft palate (Dr. Alois Monti). In rotheln and measles the tonsils 
are red and swollen early in the disease; but in simple scarlet fever, 
for the first twelve hours there is generally very little swelling of the 
affected parts, and children seldom complain of pain in the neck or in 
swallowing. After twelve or twenty-four hours the swelling com- 
mences, and the redness becomes less uniform, and more punctiform. 
This peculiar punctiform appearance may be noted often ten or twelve 
hours before the rash on the skin is visible. Patches of deposit are 
sometimes seen on the tonsils. If in malignant scarlatinal sore throat, 
however, there is, from the first, parenchymatous inflammation of the 
tonsils and the submucous connective tissue, and this condition is 
associated with well-marked nervous symptoms, a severe case with 
ulceration of the fauces may be confidently predicted. 



FEVERS. 25 

In general terms, it may be said that when the soft palate has a dif- 
fused red hue, "similar," as Trousseau remarks, u to, but deeper than, 
that of the skin," while the tonsils are not involved; when with this is 
a very hot skin, a very quick pulse, vomiting, a tongue with thick, 
creamy fur, red borders, and prominent papillae ; and with these symp- 
toms, and exposure to the presence of a scarlatinal epidemic, the phy- 
sician need not hesitate in pronouncing it scarlet fever. 

A very early symptom of scarlet fever has been insisted upon as 
,strictly pathognomonic by an Irish physician, Dr. Joseph Duggan.* 
It is that the eye assumes a peculiar brilliant and glistening stare, very 
different from the liquid, tender, watery eye of measles, and which 
once carefully noted, remains impressed on the observer's memory. 

The character of the preliminary fever often differs. In scarlatina 
it is speedily developed and high, which distinguishes it broadly from 
diphtheria, which is not marked at the outset; in measles it is of a 
catarrhal form ; while in small-pox it is often associated with very 
severe pains in the back and loins, not observed in the other exanthe- 
mata. This spine-ache is central in its position, and is less affected by 
change of posture than is the pain of lumbago, and is not confined to 
one side nor to the erector spince muscles. It is stated by some authors 
that this pain is increased in proportion with the severity of the attack 
and thus forms an important element in the prognosis; but this state- 
ment should be confined in its application to adults, as in children the 
rachialgia is rarely intense. Dr. Wilks observes that the most viru- 
lent cases of variola are almost apyretic and devoid of feverish symp- 
toms, but rapidly sink under the effects of the poison. 

In all the exanthemata the eruption makes its appearance in the throat 
or the mouth, from twelve to twenty-four hours (and in many instances 
longer) before it appears on the cutaneous surface. In small-pox, in 
scarlet fever, in measles, in all their grades, the eruption may be looked 
for in this region long before it can be detected at any other point. 

Having thus defined the special indications for a diagnosis of these 
diseases in their earliest stage, we give in the following table a synop- 
sis of their comparative clinical course and phenomena: 

* Medical Press and Circular, Feb., 1869. 



26 



DIFFERENTIAL DIAGNOSIS. 



RUBELLA OR ROTHELN. 



SCARLET FEVER. 



INCUBATION. 



Period of incubation from one to 
two weeks. 



Very uncertain; from less than 
a day to several weeks ; on an av- 
erage about twelve days. 

INVASION. 



Languor; shivering; nausea and 
vomiting; usually sore throat, but 
not severe. These symptoms may 
be so slight as to be entirely over- 
looked. 

Premonitory fever of short dura- 
tion; relieved by the eruption. 
No albumen in the urine. 



Shiverings; nausea; vomiting; 
throat very much inflamed ; sneez- 
ing and discharge from the nose ; 
convulsions occasionally in chil- 
dren. 

Great heat of skin and very fre- 
quent pulse; not relieved by the 
eruption. Albuminuria very com- 
mon. 



ERUPTION. 



Appears early and almost simul- 
taneously over the whole body — is 
sudden and general — is less marked 
on the limbs than on the trunk, and 
especially on the chest ; may first ap- 
pear upon the back, upon the chest 
or neck, upon the cheek or upon the 
forehead; travels downward. 

At first minute dots, which rap- 
idly assume the appearance of 
large, . irregular-shaped patches, 
somewhat like measles, but less 
distinct in color and form, varying 
from three-cent piece to twenty- 
five-cent piece in size. 

These patches are raised above 
the surrounding skin, especially 
toward the middle, and are of a 
darker red color at the centres. 



Fades in about four days; des- 
quamation, when it occurs, is fine 
and bran-like. 



on neck. 



On second day; first 
and face, and body; spreads rap- 
idly to limbs. 



The skin feels harsh and rough 
(like a nutmeg-grater), minute 
points of redness next appear, soon 
surrounded by deep rosy areola 
(like a boiled lobster). 



The eruption is uniform, or in 
very large patches, of a scarlet 
hue, with interspersed raised spots 
and perhaps a few vesicles; the 
rash is followed, after the seventh 
day of its appearance, by complete 
desquamation. 

The disease is communicable by 
these epithelial scales. 



FEVERS. 



27 



MEASLES. 



SMALL-POX. 



INCUBATION. 



Generally from seven 
teen days. 



to four- 1 Generally about ten days, but 
I varies from five to twenty days. 



INVASION. 



Lassitude, shivering, catarrh ; 
sneezing, discharge from nose; 
harsh cough; rarely vomiting. 
Conjunctivae, injected, and eyes 
watery; more or less photophobia. 

Fever, with hot skin and fre- 
quent pulse; rather increased by 
the eruption. 



Shivering, severe pains in the 
back; nausea. There may be a 
marked chill followed by vomiting. 



Fever often very violent, with 
bounding pulse and pain in the 
loins ; great relief from occurrence 
of the eruption. 



ERUPTION. 



Appears on fourth day, first on 
face, spreads gradually in forty- 
eight hours to the rest of body. 

Comes out in small, circular 
dots, like flea-bites. These dots 
run together and form blotches, of 
a raspberry color, and the latter 
are very prone to assume a cres- 
centic or horse-shoe shape, being 
slightly elevated above surround- 
ing skin. 

Eruption is sometimes diffused 
over the whole body in a confluent 
form, and is of a dull, deep red 
color, offering a contrast to the 
crimson or scarlet redness of scar- 
let fever. May be very dark in 
the hemorrhagic form. 

Lasts five days; followed by in- 
complete desquamation. 



Eruption at end of third or on 
fourth day ; first on lips, palate and 
forehead. 

Eruption is first papular; after 
about a day becomes vesicular, 
then pustular; on the eighth day 
of the eruption, the pustules ma- 
turate; about the twelfth the scabs 
begin to fall. The danger of con- 
tagion does not cease until desqua- 
mation is entirely completed, and 
the epithelial scales and crusts de- 
stroyed. The vesicles may be dis- 
crete or they may run together, as 
in the confluent variety, and hem- 
orrhages may take place into them 
in the hemorrhagic form. 



28 



DIFFERENTIAL DIAGNOSIS. 



RUBELLA OR ROTHELN. 



SCARLET FEVER. 



ACCOMPANIMENTS. 



Only moderate sore throat, with 
hoarseness ; swelling of the lym- 
phatic glands at the angle of jaw. 

Tongue slightly coated or nor- 
mal. Cerebral symptoms absent. 

Moderate systemic disturbance. 



Sore throat; coryza or bron- 
chitis rare. 

Tongue red; raspberry charac- 
ter. Cerebral symptoms frequent. 

Marked systemic disturbance. 



THERMOMETRY. 



" The temperature always high- 
est on first day of attack, not ex- 
ceeding 102°, next day falling to 
ioo°, and getting normal on the 
fifth day." {Fox) 

"The temperature nearly always 
sub-febrile (99.5 ° to 100.4 ) — some- 
times febrile (101.3 to 102. 2 )." 
( Wunderlich) 



No secondary fever. 



Temperature may reach 105. 6°, 
or even a higher point. It usually 
remains continuously high during 
the eruption, and it is thus " well 
distinguished from those affections 
with which, on account of other 
symptoms, it is most easily con- 
founded, and more particularly 
measles and rotheln." {Wunder- 
lich) Subsides about the tenth day. 

No secondary fever. 



DESQUAMATION. 



Minute particles of cuticle, like 
scales of fine bran. 

Always begins toward centre of 
the eruptive patch, and gradually 
extends to the circumference. 



Comes off in branny scales and 
in large patches; Occasionally 
epidermis of the hands is detached 
entire, and may be slipped off like 
a glove. This is true also of the 
feet. Itching sometimes excessive. 



Pneumonia rare. 



COMPLICATIONS. 

Pneumonia rare; pleurisy more 
I common. Endocarditis exceptional. 

SEQUELS. 



Dropsy rarely; swelling of the 
cervical glands not uncommon. 



Epidemic, 
gious. 



moderately conta- 



Bright's disease, dropsy, conjunc- 
tivitis, deafness, phthisis, chronic 
diarrhoea, glandular enlargement. 

Very contagious. 



FEVERS. 



2 9 



MEASLES. 



SMALL-POX. 



ACCOM PANIMENTS. 



Bonchitis, coryza, and redness of 
the eyes, constant; sore throat rare. 

Tongue coated, or red at edges. 

Cerebral symptoms very rare 
and not severe. 

Usually mild, but in some cases 
and in some epidemics, malignant. 



Sore throat 
bronchitis rare. 



and dry cough ; 



Tongue coated and swollen, or 
red at edges. 

Cerebral symptoms, especially 
convulsions in children, frequent. 

Always considerable systemic 
disturbance. 



THERMOMETRY. 



Temperature during preliminary 
fever may reach i05°-io6°. Within 
twelve to twenty-four hours from 
appearance of rash it sinks speedily 
to the normal. Protracted defer- 
vescence indicates a complication. 

No secondary fever, though the 
fever may increase slightly before 
eruption leaves. 



Temperature during the prelimi- 
nary fever high, often 106 ; falls 
rapidly to about 100° after erup- 
tion. Rises again during the sec- 
ondary fever and falls slowly;' a 
slight rise during desiccation. 

Secondary fever well marked in 
all cases. 



DESQUAMATION. 

Always in branny scales, not in I In scabs, crusts, and thick scales, 
patches or flakes. 



COMPLICATIONS. 



Catarrhal pneumonia is very fre- 1 Pneumonia not very frequent, 
quent, especially in adults. 



SEQUELS. 



Chronic bronchitis, phthisis, con- 
junctivitis. 



Contagion usually limited to 
children. Sometimes exists in epi- 
demic form ; soldiers in camp and 
aboriginal races suffer severely. 



Chronic diarrhoea, glandular en- 
largement, various diseases of the 
eyeballs and eyelids. 

Very communicable ; mild cases 
may cause severe or malignant 
ones. Chiefly adults. 



30 DIFFERENTIAL DIAGNOSIS. 

The specific points of diagnosis of epidemic roseola or rubeola from 
measles are clearly shown in a paper by Dr. I. E. Atkinson, of Balti- 
more.* His conclusions are as follows : 

1. Rotheln (rubella) is a specific contagious eruptive disorder. 

2. While it possesses pretty well defined characteristics which, taken 
together, justify a reasonable degree of certainty in its diagnosis, it 
has no symptom which may not be, and is not often assumed by 
measles. 

3. A sporadic case, occurring in one who has never had measles, and 
who affords no history of exposure to rotheln, may be diagnosticated 
with a fair degree of confidence, but not with absolute certainty. 

4. The unqualified diagnosis of rotheln (rubella) should only be made 
during an epidemic in which all persons exposed, irrespective of former 
attacks of measles, are liable to be affected, and in whom the symp- 
toms follow a pretty uniform type. In the absence of pronounced 
epidemic influence, a series of cases occurring in a household, a school, 
or an asylum, showing typical symptoms, may be diagnosticated as 
rotheln (rubella) with a fair degree of confidence. 

5. In sporadic cases, where neither measles nor rubella has been ex- 
perienced, a diagnosis of probable measles or rotheln (rubella) must 
be made, accordingly as the symptoms and course resemble the type 
of one or the other affection. 

In small-pox the eruption may often befell before it can be seen, 
the sensation imparted to the finger being like little shot underneath 
the skin. Its first appearance is as a simple red point or pimple, soon 
changing to a papule. The red erythematous blush of scarlatina dis- 
appears on pressure, but returns when the pressure is removed. 

Prof. Wm. Osler, of Philadelphia, and others, have called attention 
to and described a number of initial rashes, which precede, by twelve 
to twenty-four hours, the appearance of the variolous eruption. They 
are principally noticeable on the upper part of the trunk, and generally 
have the similitude of a deep, suffused flush, but vary in their physical 
characteristics. 

The pulse in variola is asserted, by some, to be pathognomonic and 

*In the American Journal of the Medical Sciences, January, 1887, No. 1S5, page 17. 



FEVERS. 3 1 

significant so early in the disease, that the malady can be positively 
diagnosticated many hours before the eruption appears. But no defi- 
nite descriptions nor tracings of this pulse have been given.* 

TYPHOID AND TYPHUS FEVERS. 

Until within comparatively few years, these two fevers were con- 
founded; and although now, in this country at least, they are distinctly 
recognized as wholly different diseased conditions, yet there are nu- 
merous instances where the clinical features of cases assimilate them 
to one or the other of these conditions, and yet fail to answer satisfac- 
torily their currently-received definitions. Such are the numerous 
gastric, nervous, simple continued, synochal, mixed, entero-miasmatic, 
typho-malarial, etc., types which are so often referred to in medical 
literature. There are, in fact, wide variations in the local features of 
this group of diseases, and it is the exception to find the classical por- 
traits of one of the group, drawn in the hospital wards of great cities, 
correspond precisely with the case as seen, modified by the numerous 
special conditions of particular regions. We shall cite some of these 
modified types, after having considered the early symptoms and broad 
distinctions of typhoid and typhus. 

Typhoid fever is peculiarly a disease of slow and insidious approach. 
For days, and sometimes for weeks, the patient is ailing; and as this 
gradual onset is known to the public, the physician is often called upon 
to pronounce an opinion as to the probability of the threatenings being 
of typhoid, long before any positive sign is present. 

The general symptoms are a sense of weakness and fatigue, loss of 
appetite, muscular soreness, headache, (generally dull, sometimes 
severe,) disturbed sleep, poor appetite, low spirits. A characteristic 
and often early symptom is epistaxis. Frequently there is a bronchitis, 
with shallow and rather frequent breathing, with some sonorous rales 
over the chest. A skilled auscultator can often pronounce from the 
character of the rales as to the presence of typhoid, as they yield a 
peculiar, dry, ringing sound. In one of his clinical lectures, Dr. Da 

*See Dr. A. S. Payne, Va. Med. Monthly, March, 1878; J. S. Conrad, Trans, of the 
Med. and Chirurg. Faculty of Md., 1874. 



32 DIFFERENTIAL DIAGNOSIS. 

Costa remarks on this : " I should be loath to rest upon this symptom 
alone, but there is something about it that often makes the diagnosis 
of typhoid special and specific."* This point is worthy of more notice 
than it has received. 

The pathognomonic symptoms of typhoid are those connected with 
the abdomen. The belly is swollen and tympanitic; there is usually 
diarrhoea with perhaps abdominal pains; rumbling near the ilio-caecal 
valve and tenderness about the right iliac fossa. The tongue is coated, 
and sometimes moved with pain; the teeth show accumulations of 
dried mucus (sordes) ; thirst is rarely excessive; vomiting is rare; the 
mind is dull, and the delirium is usually low and muttering. The 
peculiar eruption appears on the chest and belly, most frequently be- 
tween the nipple and navel, about the sixth or eighth (never before the 
fifth) day of the fever. It is in scattered, small, reddish, deleble spots, 
resembling flea-bites, which come out in successive crops. Later they 
become rose-colored, and are surrounded by an area of erythema, 
shading off into the surrounding skin. They are not elevated, or very 
slightly so, and they disappear entirely on firm pressure, but promptly 
re-appear. They give no feeling of hardness to the finger passed over 
them. These spots may appear all over the body, but are often 
wholly absent however ; and their presence, number and size do not 
seem to bear any relation to the severity of the attack. Sudamina are 
also frequently seen, but are not considered of much import. 

The prodromal symptoms above mentioned are, however, often 
varied. Dr. A. Larrabee, of Louisville, remarks that the character- 
istics of the prodromal stage, the lassitude, epistaxis, and even the 
susceptibility of the bowels to purgatives, which are valuable aids to 
early diagnosis in more northern latitudes, are not so important in the 
malarial regions of the southern and southwestern United States ;f 
and Dr. Jurgensen, of Kiel, Prussia, has given the history of a number 
of cases, with the anatomical characteristics of typhoid fever, when the 
attacks were sudden, with a well-marked chill, a high temperature 
(104 Fahr.) and quick pulse, swelling of spleen and little or no diar- 
rhoea.! Such a course is extremely rare in this country. 

* Medical and Surgical Reporter, Vol. xxviii, p. it. 
f Trans. Kentucky State Med. Soc, 1 876, p. 123. 
\Med. Times and Gazette, 1 874. 



FEVERS. 33 

In typhus the eruption usually appears as small, discrete spots, 
slightly elevated, of a dingy red color and not completely fading on 
pressure. In a short time the spots cease to be elevated, and fade less 
on pressure, and a purple mottling appears in the interjacent portions 
of skin. At a still later period — say on the eighth, ninth or tenth day 
— the spots become entirely petechial, not being at all affected by 
pressure. The eruption begins to fade about the ninth or tenth day, 
and disappears about the fourteenth, and, if there be no local compli- 
cation and the patient has not been very greatly prostrated, convales- 
cence is established between that day and the twenty-first. In slighter 
cases, however, the serious illness may continue for only about a week, 
the eruption may never be very marked, and the patient may become 
convalescent from the tenth to the fourteenth day; while in very 
severe cases the rash may become petechial at an early period, and 
may continue on the skin till near the end of the third week, and the 
convalescence may be very greatly protracted. Generally in a simple 
uncomplicated case of typhus, the pulse and temperature fall below 
the normal standard at the earlier period of convalescence, and again 
rise when the patient takes more food and is capable of some little 
muscular exertion. Usually the bowels are confined during the course 
of the disease, but such is not always the case; sometimes towards 
the height of the fever and when there is great prostration of strength, 
the bowels are relaxed, apparently from want of power in the sphinc- 
ter to retain the fecal matter; but in some cases there is profuse diar- 
rhoea during the whole course of the disease, and this independently 
of any cathartic medicine. It is impossible to base the diagnosis be- 
tween typhus and typhoid upon the confined state of the bowels in the 
former disease and the occurrence of relaxation in the latter, for it is 
not uncommon for the bowels to be confined in typhoid. So, also, 
though the cerebral disturbance is more marked in cases of typhus* 
than in typhoid, as the rule, it sometimes happens that a patient will 
pass through a marked or even severe attack of typhus without much 
delirium, retaining his intelligence to such an extent as to be able to 
answer simple questions put to him, without any apparent difficulty. 
In such cases, however, the patient, on recovery, usually has no recol- 
lection of anything that has occurred from a very early period of his 
illness till convalescence is far advanced. 
3 



34 



DIFFERENTIAL DIAGNOSIS. 



In the following table, the leading phenomena of the two diseases, 
as given by the best authorities, are contrasted, for the purpose of 
establishing their clinical distinction. The non-identity of the two 
affections is now everywhere acknowledged. (In Germany typhoid is 
often called abdominal typhus — an unfortunate title.) 



TYPHOID. 

(enteric fever.) 

Age generally from eighteen to 
thirty- five. 

Only very exceptionally contag- 
ious ; often sporadic or endemic. 

Attack generally insidious in its 
approaches. 

Duration usually fully three 
weeks; often much longer. 

Death hardly ever occurs before 
end of second week ^ generally in 
or after third week. 

Cerebral symptoms come on 
gradually ; last longer. 



Great emaciation. 

Face pale, or flush confined to 
cheeks. 

Skin hot, sometimes covered 
with acid perspiration. 

Abdominal symptoms, such as 
diarrhoea, tympanites ; intestinal 
hemorrhage not unusual. 



Epistaxis common. 
Bronchitis and sometimes pleu- 
risy. 



TYPHUS. 
(ship fever.) 

At all ages, often in persons be- 
yond middle life. 

Highly contagious, generally 
epidemic. 

Attack generally sudden; no 
lengthened prodromata. 

Duration somewhat shorter ; of- 
ten not prolonged beyond second 
week. 

Death not unfrequently occurs 
at end of first week, and often be- 
fore conclusion of second. 

Delirium or decided stupor 
comes on soon, sometimes almost 
from the onset; headache has ap- 
peared and disappeared by about 
the tenth day. 

Less emaciation; greater pros- 
tration. 

Face deeply flushed, of dusky 
hue ; eye injected. 

Skin of pungent heat, sometimes 
emitting an ammoniacal odor. 

No abdominal symptoms ; bow- 
els constipated; meteorism rare; 
no intestinal hemorrhage; some- 
times acute dysentery during con- 
valescence. 

No epistaxis. 

Pneumonia or marked conges- 
tion of the lungs, and bronchitis 
of finer tubes. 



FEVERS. 



35 



TYPHOID. 

(enteric fever.) 
Eruption light red and not usu- 
ally on extremities ; it is discrete. 

Autopsy shows morbid state of 
Peyer's patches and solitary glands; 
enlargement of mesenteric glands ; 
ulceration of mucous coats of in- 
testines; enlargement and soften- 
ing of spleen ; ulceration of the 
pharynx. 



TYPHUS. 
(ship fever.) 
Eruption of a darker color and 
all over the body. 

No constant post-mortem appear- 
ances; most common are dark-col- 
ored, liquid blood, and enlarge- 
ment of the spleen; softening of 
heart more common than in ty- 
phoid ; no intestinal lesions. 



COMPARATIVE THERMOMETRY (DR. J. W. MILLER). 

TYPHOID. TYPHUS. 



The duration of elevated temper- 
ature is very rarely less than twen- 
ty-one days; it is generally longer, 
and may be protracted to thirty- 
five days, or even more. 

The evening temperature is al- 
most constantly higher than that 
of the morning. 

The difference between the morn- 
ing and evening temperature is 
generally, throughout the case, 
greater than in typhus; and to- 
ward the end of the fever there oc- 
curs the very characteristic oscilla- 
tion of temperature, during which 
the difference is frequently five, six, 
or even seven degrees, and which 
may continue from a few days to a 
week or more. 

A high temperature is frequently 
accompanied by a pulse but slightly 
accelerated, and occasionally by a 
pulse slower than normal, and not 
infrequently dicrotic, especially 
during convalescence. 



The duration of elevated tem- 
perature is very rarely beyond 
eighteen days; it is generally 
shorter by several days, and may 
be even so short as nine days. 

The evening temperature is fre- 
quently lower than that of the 
morning. 

The difference between the morn- 
ing and evening temperature, dur- 
ing the height of the fever, or from 
about the third to the tenth or 
eleventh day, is comparatively sel- 
dom above one degree, and al- 
though about the period of defer- 
vescence the difference is some- 
times much greater, the oscillation 
is not continued over more than 
one or two days. 

A high temperature is, as a rule, 
accompanied by a high pulse. 



3D DIFFERENTIAL DIAGNOSIS. 

The varieties of fever called gastric and nervous have not been recog- 
nized as distinct types by the most recent writers. Yet there is no 
doubt that many cases of continuing fever present gastric rather than 
abdominal symptoms, and various other perceptible variants from the 
type of a mild typhoid. The following semeiological table, drawn from 
Dr. Copland's work, will illustrate this : — 

FORMS OF TYPHOID. 



SIMPLE CONTINUED TYPE. 

100-120, small, weak, irregular; 
intermittent when a dangerous at- 
tack. 



Pulse. 



Heat of surface generally rises Temperature, 
over i ocr. 



"White, foul, loaded or furred ; Tongue, 

again red at its sides, and point 
loaded with dim* yellow fur. 

Tenderness at epigastrium ; loose- Gastric 

ness or diarrhoea of an ochery hue; Symptoms, 
vomiting early. 

Pain in head, throbbing of arter- Head 

ies, brilliant expression of eyes, Symptoms, 
marked acuteness of senses, watch- 
fulness and restlessness, moaning 
and incoherent muttering, dilated 
pupils, and coma. 

A common and early complica- Lung 

tion, either of bronchial surface or Symptoms, 
congestion of substance. 

Sore throat or inflammation of Affection of 
fauces sometimes accompany. Throat. 

By subsidence of the prominent Recovery, 
morbid actions indicative of a grad- 
ual decline. 



NERVOUS TYPE. 

Soft, feeble, and quick; about 
eleventh day very quick and un- 
equal. 

Heat of skin not much elevated ; 
it may even seem natural or dimin- 
ished. 

Loaded or covered with a dirty 
mucus, afterward brown or black, 
incrusted or fissured. 

Fetor of the breath and of the 
discharges, an irregular relaxed 
state of the bowels, pain at the epi- 
gastrium, nausea and vomiting. 

Countenance pallid or transiently 
flushed, head heavy, continual rest- 
lessness, want of sleep, tremor, hear- 
ing dull, unconscious evacuations, 
low delirium, early stupor and 
coma. 

The bronchial surface is the part 
chiefly affected; substance of the 
lungs sometimes complicated. 

Sore throat, occasionally so se- 
vere as to resemble an attack of an- 
ginosa maligna. 

Often announced by a true crisis. 



Gastric fever, which ismot to be confounded with gastritis (although 
this is more properly a fever of gastric origin), is recognized by Nee- 
meyer and other competent authorities as a separate type. It com- 
mences with loss of appetite, headache and languor, followed by a 
slight chill, with marked gastric irritability, great nausea, frequent 



FEVERS. 



37 



vomiting, and constipation. There is considerable tenderness on 
pressure over the stomach, a low pulse (60 to 70 per minute), and a 
temperature at first rising slightly to (ioo° Fahr.), then falling below 
the normal as the disease advances (to 95 ° and even lower). A grave 
symptom is double vision or total loss of sight. There are no tympan- 
ites, diarrhoea, delirium, subsultus tendinum, spots, iliac tenderness, 
nor sordes, as in typhoid. Women are more liable to it than men, 
old persons than those of middle age or youth. Its outbreaks indicate 
it to be a zymotic disease, and the mortality is even higher than in or- 
dinary typhoid. The pathognomonic symptom of the disease is the 
peculiar sweetish odor of the breath; it is likened by some to the odor 
arising from hot water poured on garlic, having a slightly alliaceous 
odor ; or, according to others, it resembles a faint aroma of valerianic 
acid.* What is usually called gastric fever is really typhoid. 

Typhlitis can readily be distinguished from typhoid fever by the 
pathognomonic sign of a dense tumor in the iliac fossa, increasing, and 
exceedingly tender on pressure. 

TYPHOID AND MALARIAL FEVERS. 

TYPHO-MALARIAL (Woodward), ENTERO-MIASMATIC (Wood), OR 
REMITTO-TYPHUS (Drake). 

In order to bring into relief the broad distinctions between tne 
typhoid and malarial fevers when in their typical forms, the following 
comparative table has been prepared, which is chiefly that of Dr. E. 

M. HUME.f 



TYPHOID. 

Decomposing animal and vege- 
table matter, especially human ex- 
crement. 

Old soil; may be high and dry 
and long settled, especially where 
saturated with sewage. 

Epidemic of typhoid fever. 



Seldom after forty. 



Cause. 



Locality. 



Circumstantial 
Evidence. 



Age. 



MALARIAL. 

Emanations from marshes, damp, 
low, or new soil; always vege- 
table, never animal. 



New land, 
swampy. 



moist, low and 



Prevalence of malarial disease. 



All ages. 



* Dr. G. B. Bullard, Trans, of the Vt. Med. Soc, 1877, pp. 52-56. 
f Peninsular Journal of Medicine, Feb., 1875. 



3« 



DIFFERENTIAL DIAGNOSIS. 



TYPHOID. 

Continued without intermission 
or decided remissions. 

Lasts three or four weeks; can- 
not be cut short. 

Great nervous disturbance and 
prostration; dull, heavy, throbbing, 
persistent frontal herdache ; twitch- 
ing of muscles ; tickling of throat ; 
ringing in ears; deafness; mind 
stupid. 

Asthenic, not wild. * 

Frequent. 

Catarrhal bronchitis with some- 
times tough, tenacious sputa. 

From 70 to 140 beats per minute, 
small, irregular or dicrotic. 

Hot, even when moist; emits a 
peculiar, musty odor, pathogno- 
monic of this fever. 

Indicates an increase of tempera- 
ture from morning to evening of 
about 2 degrees, and a decrease of 
I degree from night to morning; 
commences first day 98.5 degrees, 
reaches its maximum of 104 de- 
grees on the morning of the fourth 
day; from this time the evening 
temperature ranges between 103 
degrees and 104 degrees, morning 
1 degree lower, until end of second- 
week, when it gradually declines in 
the same regular manner, always 
lower in the morning than in the 
evening, except when there is a 
complication. 

Protrudes tremblingly; is cov- 
ered with a whitish yellow coat, 
which subsequently disappears and 
is replaced by a dry, pale brown 
one, with red, glazed tip and edges; 
teeth covered with dark brown 
sordes. 

Pale, livid, muddy, or may be 
clear, with cheeks flushed. 

Foaming, light color, free from 
sediment ; frequently contains albu- 
men ; has typhoid odor like body. 



Periodicity. 
Duration. 

Nervous Im- 
plication. 



Delirium. 

Epistaxis. 

Lungs. 

Pulse. 

Skin. 

Thermometer. 



Tongue. 



Complexion. 
Urine. 



MALARIAL. 

There is either intermission or 
remission. 

Can be interrupted and cured in 
a few days. 

None, although there is some- 
times severe headache, simulating 
meningitis. 



Sthenic. 

None. 

Congested, when affected at all. 



More frequently high, full and 
bounding. 

Varies ; sometimes dry and hot ; 
odor acid and swampy; at other 
times may be normal. 

Rises rapidly to 105 degrees or 
more first day or two, and falls sud- 
denly ; is not so uuiform ; may rise 
and fall seven degrees in one day. 



Coated all 
dark-yellow coat. 



over with a heavy, 
No sordes. 



Sallow ; eyes yellow. 



Dark color, turbid, no albumen, 
except in malarial hemorrhagic 
fever. 



FEVERS. 



39 



TYPHOID. 

Diarrhoea, except in mildest Excretions 
cases; stools offensive, pea soup, from Bowels, 
bright yellow or brown ; devoid of 
mucus, but sometimes contains 
whitish flocculi. 

Tympanites occurs, giving tub Abdomen, 
shape to abdomen; pressure over Shape, etc. 
caecum produces pain and gurgling 
sound ; tenderness over spleen. 

Stomach not involved ; no severe Pain. 

pain anywhere, except when peri- 
tonitis occurs. 

Occurs during second week; Eruption, 

from one to twenty small rose-col- 
ored spots, size of pin head, appear 
on abdomen, chest or back ; do not 
extend to extremities; present no 
distinct elevation to the touch, dis- 
appearing upon pressure, but reap- 
pearing upon its removal ; last about 
three days, fade away, and a fresh 
crop appears. This eruption is 
claimed to be " peculiarly and ab- 
solutely diagnostic of typhoid 
fever." Later in the disease suda- 
mina appear. 

Great — averages one in five. Mortality. 

Inflammation and ulceration of Lesions. 

Peyer's, solitary and Brunner's 
glands; sometimes perforation of 
bowels, with peritonitis, and fatal 
hemorrhage ; inflammation and 
enlargement of mesenteric glands 
and the spleen (which sometimes 
bursts) ; the brain, stomach, liver 
and lungs sometimes inflamed. 



Bowels costive 
bilious stools. 



MALARIAL. 

dark, hard, dry, 



No tympanites or tenderness of 
abdomen. 



Gastric disturbance and vomiting 
of bile; pain in stomach and else- 
where very intense; may be 
throughout the entire body. 

Eruptions of different kinds some- 
times occur, but are so different in 
shape, feel, duration, number, extent 
and place, that they need never be 
mistaken for the typhoid eruption. 



Very slight — not one fatal case in 
a hundred. 

Hemorrhage from congestion of 
bowels rare ; congestion of stomach, 
lungs, liver and spleen — the two 
latter sometimes become enlarged. 



We shall now consider the character of a combined form of disease 
presenting in its different stages symptoms both of malarial and 
typhoid fever. 

The experience of numerous observers has proven that there is a 
complex form of fever prevalent in malarious districts, in which the 
typhoid and miasmatic elements are combined. It has been proposed 
by Dr. J. J. Woodward to call this "typho-malarial fever," a term 
which he explains to be applied " not to a specific or distinct type of 
disease, but to the compound forms of fever which result from the 



40 



DIFFERENTIAL DIAGNOSIS. 



combined influence of the causes of the malarious fevers and of typhoid 
fever." * 

The name Remitto-Typhus was given to it by Dr. D. Drake, who 
also spoke of it as " the typhoid stage of remittent or autumnal fever." 
He does not consider it a distinct disease, but a genuine hybrid of 
typhoid and remittent fevers. He remarks that in many cases the 
stage of invasion is of nearly the same length in both ; both attack males 
more than females ; and that when remittent terminates fatally, sub- 
sultus tendinum, a dry tongue and intestinal hemorrhage are some- 
times present. He has, however, never seen a decided intermittent 
pass into typhoid; nor a well-marked typhoid terminate in an inter- 
mittent^ 

During and since the war, typho-malarial fever has attracted much 
attention, and its traits have been thus distinguished from simple 
typhoid. 



TYPHOID. 

Occurs in all localities, most com- 
mon in the north. 

Invasion gradual and without re- 
mittence. 

Daily exacerbation and remis- 
sion slight. 

Diarrhoea the rule. Tympanites 
common. Abdominal tenderness 
considerable ; epigastric and he- 
patic tenderness slight. 

Temperature comparatively low. 
Delirium low and muttering. 

Spleen not involved to the same 
extent. 

Sordes on the teeth the rule. 

Peyer's glands always involved. 

Rose-colored eruption present. 

Pigment deposits absent. 



TYPHO-MALARIAL. 

Only in miasmatic localities ; 
most common in the south. 

Often begins as simple intermit- 
tent or remittent. 

Decidedly marked. 

Constipation the rule. Tympan- 
ites rare. Abdominal tenderness 
slight ; epigastric and hepatic ten- 
derness considerable. 

Temperature high, especially at 
outset. Delirium active. 

Tumefaction of spleen very 
marked. 

Sordes rare. 

Rarely involved. 

Generally entirely absent. 

Pigment deposits in various tis- 
sues and organs very common. 



* Transactions of the International Medical Congress, 1876, p. 340. 
f "Diseases of the Interior Valley of North America," p. 556. 



FEVERS. 



41 



THE TYPHOID STATE. 

It is a common error to confound the typhoid condition, which 
occurs in many diseases, with typhoid fever, properly so-called. This 
typhoid state may be developed in typhus and other fevers, in acute 
pneumonia, rheumatism, tuberculosis, pyaemia, and various renal dis- 
eases, epecially the granular or gouty kidney, and Bright's disease. 
The exciting cause in all these cases, it is believed, is the accumula- 
tion in the blood of the nitrogenous products of disintegration of the 
tissues. 

The so-called "typhoid symptoms" are a quick, soft pulse; a dry, 
brown tongue ; the phenomena and physical signs of hypostatic con- 
gestion of the lungs ; impairment of the mental faculties ; stupor pass- 
ing into coma; delirium, which is at one time acute and noisy, at 
another low and muttering, and not infrequently associated with mus- 
cular tremor; involuntary discharges. The skin is dusky, moist and 
often emitting a fetid odor. There is little thirst and often difficulty 
in swallowing. The temperature and urine vary considerably. The 
respirations are shallow and somewhat accelerated. The bowels are 
sometimes constipated, but often relaxed with offensive evacuations. 

The difference between this condition, as it supervenes in the above 
named diseases, and the true typhoid, or continued fever, may be thus 
presented : 



THE TYPHOID STATE. 

Arises in the course of ante- 
cedent disease. 

Is always traceable to debility 
or blood-poisoning from deficient 
elimination. 

Abdominal symptoms generally 
absent. 



Occasionally there may be pap- 
ules or spots of diffused rosiness, 
from dilatation of superficial capil- 
laries, but nothing like the taches 
rouges. 



TYPHOID FEVER. 

Begins insidiously without any 
history of preceding disease. 

Can often be traced to an exter- 
nal zymotic or septic influence. 

Diarrhcea, tympanites, epistaxis, 
tenderness over intestinal glands, 
pain in iliac fossa, as the rule. 

Eruption of rose-colored spots, 
coming out in crops at the end 
of the first week. 



42 DIFFERENTIAL DIAGNOSIS. 



TYPHOID FEVER. 
Intestinal hemorrhage not infre- 
quent. 

Enlargement of spleen very con- 



THE TYPHOID STATE. 
Intestinal hemorrhage not to be 
expected. 

Splenic enlargement not usual, 
except in malarious , cachexia stant. 
(ague cake). . 

Urine may show albumen or pus. j Pus not present, albuminuria 

[occurs rarely. 

MALARIAL FEVERS (PALUDISM). 

The characteristic symptom of all malarial affections is periodicity. 
It is not, however, pathognomic ; for hectic and syphilitic fevers, neu- 
ralgia and many other disorders, simulate this trait very closely. The 
diagnosis, however, in most instances is not difficult except when pois- 
oning by malaria complicates other diseases. 

Intermittent fever begins with a chill, cold extremities, pale face, 
chattering teeth and feeble pulse, followed by a decided fever, in which 
the face becomes flushed, the skin hot, the pulse full and rapid; and it 
ends with a profuse perspiration, soft, moderate pulse, and restoration 
of the secretions. This occurs at regular, definite intervals, with com- 
plete intermissions between. 

In remittent fever we find the same development of the phenomena, 
the chill, the fever, the perspiration, but without complete abatement of 
the febrile symptoms in the interval. They continue, though lessened, 
and usually have daily exacerbations. It is generally preceded by in- 
termittent. 

Between these two most common forms there are the differences 
that in intermittent fever the patient is well between the paroxysms, 
in remittent he continues ailing; in intermittent a distinct chill pre- 
cedes each attack, in remittent the chills are slight or absent; in in- 
termittent the appetite is good between the invasions, in remittent 
nausea and anorexia are present. Dr. Daniel Drake says : " If we 
suppose an ague shake to be reduced to a mere chill, but the subse- 
quent hot stage aggravated and prolonged, we shall form a just con- 
ception of the relations, in symptomatology, between intermittent and 
remittent fever."* 

* " Diseases of the Interior Valley of North America," p. 95. 



FEVERS. 43 

The more intense cases of malarial poisoning develop algid, perni- 
cious, or congestive chills ; malignant, remittent fever, and malarial hem- 
orrhagic fever. 

In congestive chill the symptoms of an ordinary intermittent are 
present, but in an exaggerated form. The chill is intense, the skin and 
even the breath seem cold ; the face is cadaveric ; the respiration is 
sighing; the pulse scarcely distinguishable; the shivering shakes the 
bed. The patient may die in the chill of internal congestion. When 
the stage of fever comes on, the pulse is full, and so quick it can 
scarcely be counted ; the skin of the body is hot while the feet and 
hands are cold ; delirium is active ; thirst intense ; the stomach is irri- 
table. The perspiration that follows brings no relief; the patient lies 
prostrate and sometimes unconscious or comatose. When the con- 
gestion affects the lung there is an air-hunger, difficult breathing, and 
bloody expectoration ; when it attacks the stomach and bowels there 
are violent spells of vomiting, foaming or soap-like white discharges, 
and great epigastric tenderness. In these cases the mind is usually 
clear ; but when the brain is involved, there is intense headache, the 
mind is dull or delirious, and coma is apt to supervene. Patients may 
die in the first or second, and but rarely survive the third chill of this 
intensity. 

The diagnosis of malignant remittent has been carefully set forth by 
Dr. Daniel Drake as follows : — 

1. The pulse does not rise in fulness and force during the exacerba- 
tion, as in other forms of remittent fever, but is generally small, fre- 
quent, weak, and variable. When the remission begins it generally 
improves slightly, but to a much less extent than in mild remittents. 

2. The feeling of abdominal oppression, and the anxiety, restless- 
ness, and gastric irritability are deeper, in this than in other forms of 
remittent fever; and these symptoms never entirely cease during the 
remission. 

3. A coldness in the hands and feet, or of the ends of the toes and 
fingers only, continues through the hot stage, while the trunk of the 
body and the head are in high fever heat. With the arrival of the 
remission, this coldness, in milder cases, is replaced by a natural tem- 
perature; but in the more malignant it continues. Many experienced 



44 DIFFERENTIAL DIAGNOSIS. 

physicians regard this as the most characteristic sign of malignant re- 
mittent. 

4. There is no time when the fever is absent; and whatever irrita- 
tions or congestions are formed in the cold stage, and whatever inflam- 
mations are set up in the hot stage, remain, though moderated in de- 
gree, throughout the remission.* 

Hemorrhagic malarial fever commences with a chill of the congest- 
ive type; and during the first paroxysms the symptoms which distin- 
guish this from all other fevers usually make their appearance. These 
are jaundiced skin and vomiting, apparently without any effort, of a 
dark fluid; the faeces dark, offensive, and tawny looking; the color of 
the skin yellowish or bronzed, and the urine colored with hcemaglobin. 
The last-mentioned is pathognomonic. Sometimes, though mixed 
with blood, the urine is profuse, which is a favorable symptom. Most 
of such cases recover; but when the urine grows scanty, and suppres- 
sion ensues, the result is said to be always fatal. f The remissions are 
irregular and often ill-defined ; and after the hot stage it has been no- 
ticed that there is no perspiration.J Pain in the back is severe and 
incessant; the stomach is irritable, and the mental powers often ob- 
scured. 

A characteristic color of the tongue in malarial poisoning has been 
observed by Professor Charles O. Curtman, M. D., of St. Louis. He 
describes it as almost uniformly present. The color of the dorsum of 
the tongue as far back as the circumvallate papillae is of a bluish-gray 
tinge, somewhat resembling that of old sheet zinc or lead. It occurs 
in various degrees of intensity, giving the impression of a coloring of 
greater or less thickness, superimposed upon the epithelial surface, 
sometimes quite thin and transparent, at other times quite opaque. In 
some cases this hue is observed without any other pronounced symp- 
toms of malaria; but in all such the distinct malarial symptoms follow. 
The disappearance of this color serves as a valuable index of the per- 
fect restoration to health.|| 

*Loc. cit. 

fDr. Greensville Dowell, " Yellow Fever and Malarial Fever," p. 213. 

% Dr. Thacker, Cincinnati Medical News, 1872. 

|| St. Louis Medical and Surgical Journal, 1869. 



FEVERS. 45 

The symptoms of malarial poisoning are multiform, and are fre- 
quently so masked and disguised that the closest observation fails to 
detect their origin. The entire organism may be affected by the poi- 
son. This is the condition of malarial toxcsmia. It is broadly char- 
acterized by a tendency to cerebral, thoracic and abdominal conges- 
tion, obstinate to ordinary remedies, and often slightly but distinctly 
periodic in exacerbations. Bronchitis, diarrhoea, simple fever, tooth- 
ache, neuralgia, ophthalmia, urticaria, and other skin diseases, even 
haemoptysis, hysteria and rheumatism, may all be caused, instituted, 
or simulated by this subtle poison in a community subject to its influ- 
ence. 

Careful examination will usually disclose evidence of periodicity in 
an increase of suffering in these cases at regular periods; sometimes 
at intervals of several days, or even weeks apart; or they may be reg- 
ularly aggravated at morning, noon, or night. Subordinated to the 
prominent symptoms, and apt to be overlooked by the patient unless 
particular inquiry is made, are slight recurrent headaches, intolerance 
of light, shiverings, or a sense of cold, or alternating heat and cold, or 
perspirations. A trace of blood in the urine, especially in the tropics, 
is a common indication of malaria. Nausea or vomiting, or a copious 
watery discharge from the bowels at periodic intervals, are often ob- 
served, especially in children.* The skin is harsh, dry, and presents 
a muddy or else a greenish-yellow hue, which is most noticeable on 
the face, neck, and arms. The appetite is capricious, the strength 
easily exhausted, the temper irritable, the mind readily depressed, and 
the energies diminished. On careful percussion the spleen is nearly 
always found to be decidedly, and the liver slightly, larger than in 
health. 

The condition of the blood in malarial poisoning has been studied 
with definite results. Dr. A. Kelsch has found that the white cor- 
puscles diminish during an attack to one-half or one-third of their nor- 
mal number, and continue less than usual so long as there is splenic 
enlargement, f Malarial anaemia is occasioned by destruction and de- 
colorization of the red corpuscles. 

* See an article on "Infantile Malarial Toxaemia," by Dr. Joel C. Hall, in the Medical 
and Surgical Reporter, Vol. xxxi., p. 147. 
f Archives de Physiologie, October, 1876. 



46 DIFFERENTIAL DIAGNOSIS. 

Various observers have reported the presence of characteristic ap- 
pearances of the blood in addition to the granular pigment masses 
derived from the red blood corpuscles. Salisbury described the toxic 
agent as palmella, Klebs as a bacillus, Moss and others, bacteria singly, 
in pairs, or in zooglea groups. The observations of Laveran seem 
conclusive, however, in demonstrating the existence in the blood of an 
organism belonging to the flagellate infusoria. Marchiafava and Celli 
have confirmed these observations, and propose the name of Plasmo- 
dium malaria for the newly-discovered organism. Councilman, of 
Baltimore, and Osier, of Philadelphia, have also found these bodies 
constantly present, and urge their importance in diagnosis, without, 
however, absolutely committing themselves to the opinion of their 
causal relation with the disease. Osier describes * the bodies as oc- 
curring both inside the red corpuscles, and free in the plasma. The 
intra-cellular form appears as either a hyaline or a darkly-pigmented 
body, filling one-third or one-half of the corpuscle, and undergoes slow 
amoeboid changes. The haemoglobin of the corpuscle is gradually 
destroyed by the organism, and the stroma becomes pale and finally 
colorless. There seems to be no doubt whatever about the amoeboid 
character of these movements, which are readily followed with a high- 
power objective. The forms occurring outside the corpuscle are still 
more remarkable. These are; (1) Small, circular, pigmented bodies; 
(2) Curious crescent-shaped organisms; and (3) An extraordinary 
flagellate body resembling an infusorian. The pigmented crescents 
have been noted by all observers, and are much more readily seen 
than the amoeboid bodies. They do not occur so frequently, and ap- 
parently only in the later stages of the disease. The flagellate form, 
also pigmented, is still less common. The movement of the flagella is 
very active, so that it brushes away the red corpuscles in its vicinity. 
The relation of these forms to one another is still doubtful, though 
they probably represent phases of development of the same organism, 
which is not a bacterium, but is classed with more propriety among 
the monads. 

* Proceedings Philadelphia Pathological Society ; also editorial in the Philadelphia Med- 
ical Times, November 13, 1886. 



FEVERS. 47 

CEREBROSPINAL FEVER (EPIDEMIC MENINGITIS, OR 
SPOTTED FEVER). 

This disease is very apt to occur in epidemic form, as is expressed 
in one of its titles. Its onset is usually sudden, often beginning with 
a chill, vomiting and intense headache, and an elevation of pulse and 
temperature. The pathognomonic symptom is that the head is drawn 
backward and downward, and the muscles at the back of the neck are 
rigidly contracted \ very tender to the touch and painful on motion. The 
pupils are also contracted. 

At an early period herpes may appear on the face or limbs, the skin 
is hyperaesthetic, and the patient cannot bear handling. After about 
four days convulsions may set in, or tetanic contractions make their 
appearance, and stupor follows, passing into a coma, preceding disso- 
lution. The bowels are usually persistently constipated, and the urine 
passes involuntarily. 

In cases tending toward recovery the acute symptoms gradually 
subside, and, after a week or two, convalescence takes place, attended 
by more or less headache and muscular contraction. 

In regard to differential diagnosis, it may be simulated by typhus or 
masked variola. The absence of tonic spasm of the post-cervical 
muscles in these diseases will aid in recognizing them. The pro- 
tracted cases, where this symptom is not prominent, may resemble 
typhoid fever. In both there is an eruption, some similar cerebral 
symptoms, and occasionally intercurrent diarrhcea. But the invasion 
of cerebro-spinal meningitis is more sudden, the headache more violent, 
and there is vomiting and constipation; while later the spinal pain, the 
herpes, the tetanic spasms and the continued headache, are broad 
distinctions. 

True tetanus is distinguished by the absence of epidemic prevalence, 
by the clearness of the mental powers, and by the history of the case 
pointing to some injury. 

Certain forms of malignant malarial fever counterfeit cerebro-spinal 
meningitis, especially during convalesence, when the affection presents 
periodical intermissions of the febrile state. The points of difference 
may be summed up as follows (Hamilton) : 



4S DIFFERENTIAL DIAGNOSIS. 

CEREBRO-SPINAL MENIN- CONGESTIVE PERNICIOUS 
GITIS. MALARIAL FEVER. 

Inceptive chill not marked. I Chill quite marked. 

Disease epidemic, and chiefly Endemic and common to all 
anions children. 

Muscular spasms the rule. 

Bowels constipated. 



Muscular spasms very rare. 
Not usually so. 



, Pulse and temperature do not Both subject to great variations, 
suffer rapid variations. ' feeble and irregular. 

Temperature does not undergo Undergoes decided periodical 
periodical changes. changes. 

Face flushed; eruption before Complexion sallow; no eruption, 
fourth day. 

Delirium and coma not affected All symptoms modified usually 
by large doses of quinine. by large doses of quinine. 

Increase of fibrin and rapid Malarial organisms can be de- 
coagulation of blood when drawn, tected in the blood. 

In distinguishing it from other head affections it should be observed 
that, while pain in the head, vomiting, epileptiform attacks, disease 
of the optic discs, emaciation, eruptions, involuntary rnicturition, are 
symptoms found in many of them, the sudden onset of fever, pain 
in the back of the neck, the stiffness of the muscles of the neck. 
and retraction of the head, are sufficient to separate cerebro-spinal 
meningitis from hydrocephalus acquisitus, basilar meningitis, and tumor 
of the brain, diseases to which, in its symptoms, it is nearly allied. 

It may also be noted that Dr. Hayden, of Dublin, a competent au- 
thority*, states that he never saw a case of cerebro-spinal meningitis 
unattended by pains in the calves of the legs, and he should make a 
presumptive diagnosis from the presence .of that symptom alone. 

Dr. Dowse, of London, has insisted on the importance of distin- 
guishing sporadic from epidemic cerebro-spinal meningitis. He main- 
tains that in its epidemic form the sensorium is more or less affected 
from the first, and the membranes over the superior cerebral convolu- 
tions, cerebellum, and posterior columns of the cord, including the 
nerve substance, are primarily, if not wholly, the seats of lesion. In 



FEVERS. 



49 



the sporadic form, on the contrary, the sensorium and special senses 
are only slightly influenced, and the inflammation centres itself upon 
the meninges at the base of the brain and the anterior columns of the 
cord. He therefore gives to the latter affection the name of occipital or 
basic cerebrospinal meningitis, in contradistinction to the former well- 
known disease. He draws his conclusions and diagnosis from signs 
and symptoms, as evidenced in the following table : 



EPIDEMIC CEREBRO-SPI- 
NAL-MENINGITIS. 

Attack sudden, without any spe- 
cial predisposing cause. 

Apparently of a contagious or 
infectious origin. 

Sensorium affected from the first. 

Excito-motor spasms of a tonic 
character in groups or groupings 
of muscles, with marked loss of 
cutaneous and muscular sense. 

Reflex movements common. 

Vomiting urgent and uncontrol- 
lable. 

Temperature rarely exceeds 

100°. 

Purpuric maculae diffuse and 
general. 

Death usually takes place from 
coma. 

Prognosis grave. 

Post-mortem appearances reveal 
the membranes over the superior 
cerebral convolutions and posterior 
columns of the cord as the seat of 
lesion. 
4 



SPORADIC OR BASIC CERE- 
BROSPINAL MENINGITIS. 

Attack commences gradually 
and resembles an onset of acute 
rheumatism. 

Usually arises from exposure to 
cold, exhaustion, and privation. 

Sensorium never affected until 
the last stage. 

Incoordination of movement, 
with cutaneous formication, partial 
anaesthesia, muscular hyperalgia, 
but no tetanic spasms. 

Reflex movements rare. 

Vomiting not so severe. 

Temperature often rises to 105 . 

Maculae never seen in the desu- 
date form. 

Death usually takes place from 
apncea or exhaustion. 

Prognosis hopeful ; much affected 
by treatment. 

Post-mortem appearances reveal 
the membranes over the base of 
the brain and over the anterior 
columns of the cord as the prime 
seat of lesion. 



50 



DIFFERENTIAL DIAGNOSIS. 



-The distinction has, however, not been wholly accepted by Ameri- 
can authorities. Dr. Da Costa questions the main point of difference 
— the temperature ; and Dr. Alfred Stille writes : " The whole med- 
ical literature does not contain a single case of sporadic idiopathic 
cerebro-spinal meningitis with the characteristic sudden onset of the 
epidemic disease." From that writer's admirable monograph and his 
article in Pepper's System of Medicine, we extract the following ex- 
haustive comparison of meningitis and typhus,* with which it has often 
been confounded: 



EPIDEMIC MENINGITIS. 

A pandemic disease. Occurs 
simultaneously in places remote 
from one another, and without 
intercommunication. 

Attacks all classes of society. 
Is never primarily developed by 
destitution, squalor, or defective 
ventilation. 

Is not contagious. 

Attacks more males than fe- 
males. 

Attacks more young persons 
than adults. 

Generally occurs in winter. 

Eruptions are absent in at least 
half of the cases; they occur 
within the first day or two. 

The eruptions are various ; they 
include erythema, roseola, urti- 
caria, herpes, etc. Ecchymoses 
are common. 

Headache is acute, agonizing, 
tensive. 



TYPHUS FEVER. 

An epidemic disease, due to 
local causes and spreading by 
intercommunication. 



Attacks the poor, filthy, and 
crowded alone. 



Contagious in a high degree. 
Both sexes equally affected. 

More adults than young persons. 

Epidemics irrespective of season. 

Eruption rarely absent, and ap- 
pears about the fifth day. 

Eruption always roseolous and 
then petechial. Ecchymoses are 
rare. 

Headache dull and heavy. 



* Still6. Pepper's System of Medicine, Vol. I, Philadelphia, 1885, page 827. 



FEVERS. 



51 



EPIDEMIC MENINGITIS. 

Delirium often absent; often 
hysterical, sometimes vivacious, 
sometimes maniacal. Generally 
begins on the first or second day. 

Pulse very often not above the 
natural rate; often preternaturally 
frequent or infrequent. Is subject 
to sudden and great variations. 

The temperature is lower than 
that recorded in any other typhoid 
or inflammatory disease. It is also 
very fluctuating. 

The body has no peculiar smell. 

The tongue is generally moist 
and soft, and if dry, is -not foul. 
Sordes on teeth rare. 

Vomiting is an almost constant 
and urgent symptom, especially in 
the first stage. 

Pains in the spine and limbs, of 
a sharp and lancinating character, 
are usual. 

Tetanic spasms occur in a large 
proportion of cases, and within the 
first two or three days. They are 
due to an exudation on the me- 
dulla oblongata and spinalis. 

Cutaneous hy£eraesthesia is a 
prominent symptom. 

Strabismus is common. 

The eyes, if injected, have a 
light red or pinkish color. 

The pupils are often variable 
and unequal. 



TYPHUS FEVER. 

Delirium rarely absent; usually 
muttering. Rarely begins before 
the end of the first week. 



A slow pulse exceedingly rare. 
Its rate usually between 90 and 
120. 



The temperature is always ele- 
vated, and does not fall until the 
close of the attack. The skin is 
hot, burning, and pungent to the 
feel. 

The mouse-like smell is charac- 
teristic. 

The tongue is generally dry, 
hard, and brown, and the teeth and 
gums fuliginous. 

Vomiting is rare and not urgent. 



The pains, if any, are dull and 
apparently muscular. 

Tetanic spasms are unknown in 
typhus. Convulsions sometimes 
occur, due to pyaemia. 



The sensibility of the skin is 
usually blunted. 

Strabismus is rare. 

The blood in the conjunctival 
vessels is dark. 

The pupils are equal and con- 
tracted. 



DIFFERENTIAL DIAGNOSIS. 



EPIDEMIC MENINGITIS. 

Deafness and blindness are often 
complete and permanent. 

Duration very indefinite, but 
generally from 4 to 7 days. 

Relapses are common. 

The blood is often fibrinous. 

The lesions, except in the most 
rapid cases, consist of a plastic or 
purulent exudation in the meshes 
of the cerebro-spinal pia mater. 

Mortality from 20 to 75 per cent. 



TYPHUS FEVER. 

Deafness almost always ceases 
with convalescence. Blindness 
never follows typhus. 

Duration from 12 to 14 days. 

Relapses are rare. 

The blood is never fibrinous. 

In typhus no inflammatory le- 
sions exist. 



Mortality from 8 to 40 per cent 



ACUTE TUBERCULAR (GRANULAR) MENINGITIS. 

This serious disease, which usually occurs during adolescence, is 
apt to be confounded, especially in the adult, with typhoid or typhus 
fever, the exanthemata, and pneumonia. The following characteristics 
of the disease, as given by Drs. Reginald Southey and Hamilton, 
will serve to distinguish it: 

1. The prodromal symptoms of this form of meningitis are well 
marked. The history of the case usually records an illness that has 
endured some two or four weeks, but one which has not attracted 
much attention until distracting headache, with some delirium at night, 
has supervened. 

2. Vomiting is generally the first and most important symptom. 
Headache is invariably present. 

3. After two or three days there is a marked rise of temperature, 
say from ioi° to 105 °, with greatly increased pulse. 

4. The bowels are constipated and not tender to firm pressure. 
Very little nourishment is voluntarily taken. The abdomen becomes 
retracted, and the aspect of the patient, with half-open eyelids, or some 
slight paralysis of these, becomes highly diagnostic. 

5. There is no characteristic rash. The so-called tdche cerebrale of 
this form of meningitis is not a true eruption, but is produced by pres- 



FEVERS. 5 3 

sure or contact. When the finger is drawn across the skin of the fore- 
head it leaves a vivid red mark, which has been considered a patho- 
gnomonic sign of the disease. 

6. The skin is hyperaesthetic, the delirium slight and transitory, the 
temper irritable, obstinate and unaccommodating. 

7. There are general muscular pains, followed first by stiffness, and 
then by slight paralysis, as shown in the imperfect coordination of the 
muscular movements also in tremblings and twitchings. The muscular 
pain and stiffness are often first complained of in the nape of the neck, 
and then in the muscles of the back. 

8. Slight epileptiform convulsions are observed, followed by paraly- 
sis of motion in the limbs or parts convulsed; this paralysis being 
most usually of a transitory or temporary kind. Among the paraly- 
ses most characteristic are those affecting the optic commissure and 
oculo-motor tracts, causing a slight internal squint, with dilated in- 
active pupil of one eye, with drooping of the same eyelid, and paraly- 
sis of the facial nerve upon one side. The paralysis of the limbs, 
although usually hemiplegic, is seldom one that invades the body 
upon one side in its entirety. Further, its mode of attack is gradual ; 
usually, the arm and leg are affected upon the same side, even when 
the facial muscles are not involved. 

YELLOW FEVER. 

The name Yellow Fever is misleading, as the coloration of the skin 
to which it refers is not an invariable nor even a common sign of the 
disease. According to Dr. Greensville Dowell,* the skin does not 
turn yellow in more than one case in six, and many die before there 
is the least appearance of yellowness even in the eyes. Of those who 
die after the black vomit has set in, not more than one in three pre- 
sents the yellowness. 

The most pathognomonic sign of the disease is the black vomit. It 
is brownish-black, semi-fluid, with a glistening reflection and acid re- 
action, and varies in quantity from a mere stain on a handkerchief to 
many pints in the twenty-four hours. It, however, is not thrown up 
in more than one in three fatal cases. 

* " Yellow Fever and Malarial Diseases." 



54 



DIFFERENTIAL DIAGNOSIS. 



The usual course of the disease as witnessed in the southern and 
southwestern States is as follows: 

1. Onset with a chilly feeling along the spine, passing into actual 
rigor. 

2. Pain in the head, severe in proportion to the malignancy of the 
disease. 

3. Fever slight, tending to perspiration. 

4. Remission after a period varying from twenty-four hours to five 
days. 

5. The secondary fever, commencing usually without a chill; it runs 
an indefinite course. 

The discoloration begins at the white of the eye, and extends over 
the skin of the forehead, chest, abdomen, and extremities. The urine 
is high-colored, and stains linen, and in some cases the perspiration 
gives the same yellowish stain. 

The shades which separate the symptoms of one fever from those of 
another, in warm climates, are sometimes of such gentle gradation 
that prima facie they may seem to belong to one and the same disease; 
this more especially refers to the yellow and remittent type of fevers, 
between which so slight is sometimes the distinction, that bilious re- 
mittent has frequently been considered and classified as true yellow 
fever; for in the prominent symptoms which appear in both yellow 
and remittent fever, a great similarity obtains : both take their origin 
in paludal soils; both in their course offer symptoms of so seemingly 
similar a nature that the shades of difference are so slight as to fre- 
quently escape even a good observer, and cause him to fall into error. 
But this apparent similarity vanishes on close and continuous inspec- 
tion, for then essential and distinctive marks are observed, which 
stamp each with an individuality, and which characterize each as a 
separate disease, distinct in its essence, and differing signally the one 
from the other. These differences may be summarized as follows 
(J. J. L. Donnet, Da Costa, Dowell, and others): 



YELLOW FEVER. 

Is essentially of an infectious na- 
ture, and found in cities. 



BILIOUS REMITTENT. 

Is not of an infectious nature, 
and usually found in fhe country. 



FEVERS. 



55 



YELLOW FEVER. 
Chiefly vigorous and young con- 
stitutions fall victims to it. Colored 
population less liable than white. 

Restricted chiefly to the yellow 
fever zone. 

Is of a continued type; remis- 
sions not marked. 

Temperature in bad cases very 
high. 

Usually attacks at night 

Severe nausea and vomiting 
throughout. Epigastric tenderness 
early and decided black vomit. 
Headache occipital. 

Hemorrhages from the gums 
and various parts of the body. 

Tongue clean or but slightly 
coa?ed; pulse variable, becoming 
slow in the last stages. 

Eye highly injected and humid; 
expression often fierce or anxious. 

Pain in the back very severe; 
also pain in the calves and over 
the eyes. . 

Delirium rare; mind generally 
clear and cheerful. 

Urine generally albuminous ; 
suppression common. 

Muscular prostration slight; con- 
valescence rapid; no sequelae. 

Liver affected and^. slightly en- 
larged. 

Spleen not affected. 

One attack- affords an almost 
certain immunity. 



BILIOUS REMITTENT. 

All ages and constitutions are 
liable, and the weakest most so. 
Colored population liable. 

Is to be found in all parts of the 
world where marshy soils prevail. 

Remissions observed in the 
morning. 

Temperature not extraordinarily 
high. 

Usually attacks in daytime. 

Nausea and vomiting moderate. 
Epigastric tenderness slight. Head- 
ache frontal. 

No hemorrhagic tendency. 

Tongue heavily coated; pulse 
varies little, remaining quick until 
convalescence sets in. 

Eye and physiognomy not pe- 
culiar. 

Rachialgia slight or absent; 
headache moderate. 

Delirium frequent; mind always 
dull. 

Albuminous urine rare; sup- 
pression also rare. 

Muchmuscularprostration; con- 
valescence slow; sequelae various 
and tedious. 

Liver not affected. 

Spleen invariably affected. 

One attack seems rather to pre- 
dispose to others. 



S6 



DIFFERENTIAL DIAGNOSIS. 



YELLOW FEVER. 

Mortality very high. 

Peculiar smell often perceptible. 

Never merges into intermittent. 

Treatment unsatisfactory; qui- 
nine useless. 

Autopsies show great conges- 
tion, inflammation, ulceration, and 
softening of the stomach. Liver 
enlarged, fatty, yellowish in color, 
its secreting cells filled with oil 
globules. Heart often exhibits dis- 
integration of the muscular fibres. 

Micrococcus xanthogenicus(?) in 
blood and the urine (Freire). 



BILIOUS REMITTENT. 

Mortality slight. 

• No peculiar smell observed. 

Often merges into intermittent. 

Quite amenable to treatment; 
antagonistic power of quinine be- 
yond question. 

Autopsies show congestion of 
the stomach, but rarely inflamma- 
tion. Liver of an olive or bronze 
hue, not fatty. Spleen enlarged. 



Plasmodium malarise, or malar- 
ial bodies of Laveran, can be found 
in the blood. 



RELAPSING FEVER. 

Of late years epidemics of this disease have appeared at various 
points in this country. It is eminently contagious in character, and a 
physician should be prepared to recognize it early. The invasion is 
sudden, the fever soon developed and high, the pulse very rapid, the 
skin often jaundiced, and the temperature elevated (io6°-io7 c ). To- 
ward the close of the first week the symptoms rapidly subside, and 
convalescence seems at hand ; but after about another week the symp- 
toms all return with as much violence as ever, to again disappear, as a 
rule, after four or five days. 

The epidemic prevalence of the disease, its sudden invasion, the 
persistence without remission of the high febrile symptoms, and the 
afebrile interval, give it a peculiar physiognomy. 

The characteristic feature of the disease, asserted by some to be 
truly pathognomonic, is the presence in the blood of the spirillum 
Obermeyeri. The following method of demonstrating them is recom- 
mended by Dr. R. Albrecht, of St. Petersburg: * 

* St. Petersburg Med. WoQhenschrift, June, 1878. 



FEVERS. 



57 



Spread out a drop of blood on a slide, not too thin; let it dry; treat 
it with a drop of acetic acid, and repeat it in a few seconds. By this 
means all the fibrin and blood-corpuscles will be destroyed and dis- 
solved, and after careful washing away of the acid with distilled water, 
and final drying, the preparation is ready for use. With a little care 
in washing, which must not be in a stream, the spirilla are not lost, 
especially if the preparation has been dried for six to twelve hours be- 
fore being treated with acetic acid. The glass slide then looks quite 
transparent, and, at the place where the drop of blood was, it looks a 
little dusty. Under the microscope the nuclei and nucleoli of the 
white blood- corpuscles are visible, and between these the spirilla lie 
in great numbers and in the most distinct arrangement and position, 
showing up very beautifully and distinctly. They give the impression 
of being thicker than they generally are, probably because they are no 
longer imbedded in a highly refracting substance — pla'sma. 

Relapsing fever is liable to be mistaken for one of the forms of con- 
tinued fever. Its epidemic prevalence will naturally put the physician 
on his guard. It is, moreover, especially a disease of the lower classes, 
who suffer from insufficient food and filthy surroundings. In most 
cases it is associated with jaundice, which is a rare complication in 
typhoid. When the disease rapidly abates, and this cessation is fol- 
lowed by the characteristic relapse, no reasonable doubt as to its 
nature can be entertained. The main distinctions between relapsing 
and typhoid may be thrown into a comparative view, as follows : 



RELAPSING FEVER. 
Invasion sudden. 

Bowels generally constipated. 
Conjunctivis occurs early. 

Liver engorged, skin yellow, 
tenderness over epigastrium. 

Temperature high, io$°-ioy°. 



TYPHOID FEVER. 

Invasion gradual, with epistaxis ; 
no chill. 

Generally diarrhoea. 

No conjunctivitis; eyes bright 
and clear. 

No yellowness; tenderness over 
right iliac region. 

Temperature during first week 
rarely above 104 . 



53 



DIFFERENTIAL DIAGNOSIS. 



RELAPSING FEVER. 

Fever abates in three or four 
days, with critical sweats; diminu- 
tion or cessation of the febrile 
symptoms, with subsequent re- 
lapse. 

Spirilla in the blood. 

Splenic enlargement. 

No characteristic eruption. 



TYPHOID FEVER. 

These phenomena absent; symp- 
toms continuous for three or four 
weeks. 



No spirilla. 

Spleen only moderately enlarged. 

" Rose spots,'.' inflammation of 
Peyer's glands. 



CHAPTER II. 
DISEASES OF THE BLOOD. 

Contents. — The Dyscrasice — The Arthritic, Dartrous, or Rheumatic 
Dyscrasia — The Scrofulous or Strumous Dyscrasia — The Tuberculous 
Dyscrasia — Rheumatism — Chronic Rheumatism — Gout — Rheumatic 
f Arthntis — Pernicious Ancemia and Leukemia. 

THE DYSCRASLE. 

As is justly remarked by Professor Theodor Billroth, in his Sur- 
gical Pathology, while it is true that there are some objections to the 
employment of the term dyscrasia, as committing one to a humoral 
pathology, these are overbalanced by the fact that there are certain 
well-defined, long-recognized, inherited physical peculiarities, which 
render the person possessing them unusually prone to certain diseases 
and complications, and which lend a complexion of their own to very 
many affections seemingly remote in form and pathology. 

These constitutional tendencies may as well be known by the term 
Dyscrasice as by any other, since their existence cannot well be denied. 

The principal dyscrasiae are : i. The arthritic, sometimes called dar- 
trous or rheumatic, believed to be pathologically akin to lithaemia, 
gout, and rheumatism; 2. The strumous, or scrofulous; 3. The tuber- 
culous, or phthisical ; the last two mentioned, in the opinion of some, 
being merely the outgrowth of an inherited syphilitic taint. 

I. THE ARTHRITIC, DARTROUS, OR RHEUMATIC 
DYSCRASIA. 
This form of blood poisoning has been aptly termed, by Mr. Jona- 
than Hutchinson, "the basis-diathesis on which both gout and rheu- 
matic arthritis are built, and which, to a large extent, is indifferent and 
common to both." When a man with such a diathesis becomes 
affected with a renal disease, gout develops itself; otherwise he will 
probably have rheumatism. In many families it has been observed that 

(59) 



60 DIFFERENTIAL DIAGNOSIS. 

the males have gout, the females rheumatism. The explanation is not 
far to seek.* In another lecture Mr. Hutchinson describes gout as 
" chronic rheumatism plus a dietetic derangement." 

Many skin diseases, nervous affections (so-called), " cramp colic," 
headaches, sciatica, vertigoes, palpitation, and obstinate dyspepsia, are 
really latent gout (lithaemia). In such cases there is usually a history 
of antecedent or hereditary rheumatic diathesis, frequent acid eructa- 
tions, the emission of pale, limpid, acid urine, of low specific gravity, 
and with traces of sugar or albumen, or both; some varicosity of the 
veins ; the nails are brittle ; and there is slight redness around the eye, 
indicative of mild chronic conjunctivitis (Dr. J. Russell Reynolds). 

The following are the signs, as stated by Professor Hardy, of Paris : 
Persons who have this diathesis appear to enjoy good health, but their 
skin is habitually dry and their perspiration scanty. They often expe- 
rience a lively itching without eruption. The appetite is generally 
well developed, and they are apt to eat a much greater quantity of 
food (especially animal food) than others in analogous conditions. 
Another important peculiarity is the extreme sensibility of the skin, 
and the facility with which it is influenced by the lightest and most 
fugitive impressions. Sometimes general excitement, alcoholic excess, 
watching, use of coffee, of certain kinds of food; sometimes a local 
excitement, irritating frictions, or the application of a plaster, will give 
rise to an eruption, often ephemeral, which reveals a peculiar predis- 
position of the economy, and the existence of a latent vice which 
needs but a favorable occasion to manifest itself. 

To this diathesis Hardy ascribes eczema, lichen, psoriasis, and 
pityriasis, among diseases of the skin.f 

Mr. Prescott Hewett adds that when a patient complains of dys- 
pepsia, more or less troublesome, frequent deposits of lithates in the 
urine, slight eczematous eruptions on the skin from time to time, 
anomalous wandering pains in various muscles, sharp, deep-seated 
pains in the tongue, continuing for or two three days, and then disap- 
pearing altogether for a while, crackling about the cervical spine on 

* Medical Times and Gazette, June, 1 876. 
f Maladies de la Peau, Paris, i860. 



DISEASES OF THE BLOOD. 6 1 

slight movements, some, it may be very slight, knottiness about the 
smaller joints of the ringers — we may be very certain that he has the 
arthritic diathesis. 

Sir James Paget adds to the above: Small (chalky) nodules in the 
cartilages of the ears (tophi); nodular enlargement of the knuckles; 
thickening of the cutis, with subcutaneous bursae over the knuckles, 
chiefly between the first and second phalanges of the fingers; thicken- 
ing of the palmar fascia, adhering to the cutis, and producing contrac- 
tion of the fingers ; spontaneous pain in the tendo-Achillis ; pain in the 
heel ; frequent and persistent erections at night, not connected with 
any sexual feelings; "burning soles" and "burning palms;" sensations 
of heat ; tingling and burning patches of the skin of the thighs, with- 
out external appearances of redness or eruption ; patches of " dry 
eczema." 

In such patients an injury may be followed by a well-marked attack 
of gout ; or the trouble may linger, with pain and occasional swelling, 
and with constantly increasing distrust of surgery and the surgeon, till 
some one suspects the existing taint of the arthritic diathesis, and act- 
ing on the suspicion, addresses his remedies to it, and promptly cures 
the local trouble. The disorder known as rheumatic fever, or acute 
articular rheumatism, has been ascribed by Maclagan to an infection 
introduced from without into a system predisposed to the influence. 
Heuter, Reckinghausen, and Klebs declare the active agent to be a 
variety of bacteria — a micrococcus. 

(The points of diagnosis between the gouty diathesis and chronic 
rheumatism, as summed up by Fothergill, are given on page 65, in 
the section devoted to " Diseases Likely to be Confounded with 
Rheumatism.") 

II. THE SCROFULOUS OR STRUMOUS DYSCRASIA. 

Sir James Paget defines the principal signs of scrofulous constitu- 
tion to be the occurrence of slowly progressive and long abiding 
inflammation, provoked by less causes than would excite inflammation 
in healthy persons, the inflammatory process tending to the production 
of "cheesy" matter; the middle permanent incisors, with their borders 
barred, crenated, thin and brittle ; the mucous membrane of the lower 



6 2 DIFFERENTIAL DIAGNOSIS. 

turbinated bone swollen, puffed and congested ; a long abiding ozaena 
in early life, with frequent or daily discharge of scabs ; general swell- 
ing, with glandular enlargement of the whole naso-palatine mucous 
membrane ; a granular pharanx, with its lining membrane more or less 
thickly scattered with prominent glands ; the perforating ulcer of the 
nasal septum — these are some of the minor signs. Still more positive 
are enlarged and suppurating lymph-glands discharging curdy pus, 
and slowly healing with red-banded and barred scars ; pustules by the 
edge of the cornea ; frequent impetigo with swollen glands ; periosteal 
swellings of the phalanges ; chronic thickenings of synovial mem- 
branes ; obstinate otorrhcea. If a patient is found to have or to have 
had any few of these, he may justly be pronounced scrofulous, and 
scrofula may be suspected in any localized morbid process in him. 
Or, if these diseases are known to have occurred singly or together in 
many members of a family, we should look out for scrofula as an ele- 
ment of whatever disease may appear in any member of that family. 

Dr. Francis Delafield, of New York city, observes* that practi- 
tioners in this country see so little of scrofula comparatively that it is 
difficult for them to appreciate the prominent place it holds in the 
minds of physicians in European countries. It is a condition which is 
hardly susceptible of a definition, and yet it is not hard to unders:^::d 
what is meant by the term. 

It means this : When an individual acquires an inflammation of the 
mucous membrane, of the skin, of the joints, of the bones, of the 
genito-urinary apparatus, or of almost any part of the body, such an 
inflammation usually runs an acute course and terminates in resolution, 
or in suppuration, or in the formation of organized new tissue But, 
if the inflammation, instead of doing this, simply reaches a certain 
point and stays there, and then, instead of resolving or suppurating 
merely, goes through a succession of degenerative changes, such an 
inflammation is said to be scrofulous. 

The scrofulous inflammations have several well-marked characteris- 
tics. They are very slow in their progress ; they are very rebellious 
to treatment ; they are accompanied by an extensive cellular infiltra- 
tion of the inflamed parts, so that when the degenerative changes en- 

* N. Y. Medical Record, vol. x., p. 338. 



DISEASES OF THE BLOOD. . 63 

sue there is large destruction of tissue. The degeneration which 
occurs in the products of such a scrofulous inflammation is peculiar in 
its nature ; it is commonly called cheesy degeneration, and consists in 
the transformation of the products of inflammation into a dry, yellow 
mass, composed of amorphous granular matter. Examples of this 
form of inflammation will at once suggest themselves. Caries of the 
vertebra, hip-joint disease, white swelling of the knee-joint, scrofulous 
orchitis, and enlarged lymphatic glands, are all of frequent occurrence. 
Irt a number of instances of scrofulous inflammations, an examination 
of the caseating product has revealed the presence of bacilli, which 
present characters almost if not quite identical with those of tubercu- 
losis bacilli* to be discussed on another page. (See page 65.) 

III. THE TUBERCULOUS DYSCRASIA. 

There are families in which the children, while apparently healthy 
during their development, perish early in adult life with tubercular 
manifestations, especially in the lungs. This indicates a peculiar in- 
heritance, which may be called the tuberculous dyscrasia. More fre- 
quently the children of decidedly strumous patients die in infancy, with 
tubercular meningitis, which furnishes ground for the belief that in 
many instances tubercular disease is brought about by the strumous 
dyscrasia; and, indeed, it is by many identified with it. The physical 
characteristics of scrofulous subjects belong also to the majority of 
consumptives, in a greater or less degree. Others are predisposed to 
the disease through defective oxygenation caused by unfavorable form 
of the thoracic walls. But the researches on this subject are still 
incomplete, and it is well to bear in mind the words of Dr. A. T. H. 
Waters : — 

" There is no temperament which does not furnish victims to con- 
sumption ; nor can we say that there is any conformation of the body 
which is characteristic of the phthisical. I have seen men and women 
with the best developed frames and the most ample chests attacked 
with phthisis. You must not, therefore, be misled, by the existence of 
these conditions, by the appearance of robustness in your patients, into 
imagining that they cannot possibly become the subjects of this dis- 
ease." 

* Klein. Micro-Organisms and Disease. London, 1884, p. 118. 



64 



DIFFERENTIAL DIAGNOSIS. 



The diagnosis of these different conditions is made less difficult by 
bearing in mind their peculiar tendencies and characteristic manifesta- 
tions, as set forth in the followiug table : 



SCROFULOSIS. 
More particularly limited 
to childhood. 



Affects especially the lym- 
phatic glands (causing ab- 
scess), the mucous membranes 
(ophthalmia), the skin (ob- 
stinate cutaneous diseases, 
especially the pustular) and 
bones (caries and necrosis,) 
indolent abscesses (cold ab- 
scess). Frequently resulting 
in phthisis and hydrocephalus. 



Generally afebrile. 

Temperament phlegmatic ; 
mind and body backward; 
skin muddy ; upper lip thick ; 
nostrils wide and alse thick- 
ened. Abdomen tumid ; ends 
of bones large ; shafts thick. 
Otorrhcea, ozaena, ophthalmia 
common. 



Bacilli present in caseating 
glands. 

Mercury prohibited. 



TUBERCULOSIS. 

Not specially limited. 



Affects internal organs 
(phthisis, hydrocephalus, per- 
itonitis, tabes of mesenteric 
or bronchial glands). 



INHERITED SYPHILIS. 

Manifests itself early, gen- 
erally before third month 
(from fourteen days to six 
weeks). 

Prominent symptoms : — 
Cachectic appearance, snuf- 
fles, condylomata around the 
anus. Child thin, poorly 
nourished, muscles flabby. 
Skin brownish, cracked, thick 
and rough. Fontanelle open ; 
ossification slow. Posterior 
cervical glands enlarged. 
Second set of incisors charac- 
teristic (Hutchinson teeth). 
The central incisors short, 
narrow and thin, chisel- 
shaped ; edges soon become 
notched and broken; also 
striped or ribbed horizontally. 
Hair thin, and may have 
alopecia. Eruptions copper- 
colored and chronic; gener- 
ally dry, but may be pustular 
(erythema, lichen, psoriasis 
and eczema, or impetigo, ec- 
thyma and pemphigus), often 
seen on palms of hands or 
soles of feet. Liver enlarged 
(albuminoid). Ascites com- 
mon, with tympanites. 

Pyrexia only in complica- 
tions. 

Nervous system highly Physically and mentally 
developed ; mind and body infenor in structure, and slow 
active ; organization delicate I in movement ; inactive, dull 
and refined. " Thin skin, 
clear complexion, the surface 
veins distinct, eyes bright, 
pupils large, eyelashes long, 
hair silken, face oval, ends of 
bones small, shafts thin, limbs 
straight." (Tenner). 



Pyrexia marked in acute 
cases, irregular in chronic. 



Bacilli in products. 

Mercury only for tempo- 
rary indigestions, etc., used 
carefully. 



and often cachectic looking. 



No bacilli detected. 



Mercury the sheet-anchor. 



DISEASES OF THE BLOOD. 65 

They resemble each other in hereditary character, their familiar 
manifestations being readily induced by defective hygienic conditions. 

EHRLICH'S METHOD FOR DETECTING TUBERCLE 

BACILLI. 

A power of 400-500 diameters is required of the microscope which 
should also be provided with a sub-stage condenser to flood the field 
with light. " A fragment of thick opaque sputum is to be taken in 
forceps, placed on a cover glass, and spread in a thin layer by means 
of a second cover glass. The prepared slide is to be passed slowly 
through an alcoholic flame or that of a Bunsen burner, till the layer of 
sputum is dried. A saturated alcoholic solution of methyl-violet, or 
fuchsin, is made and filtered and added, drop by drop, to a filtered sat- 
urated solution of aniline oil, shaken in water. The color is to be 
added with stirring till an opalescent film forms on the surface of the 
mixture. The slide containing the dried sputum is to be placed in or 
on this staining fluid, and allowed to remain for half an hour or less, the 
application of warmth hastening the process, when it is removed and 
the specimen is decolorized in a solution of one part of nitric acid in two 
parts of water. The preparation is then washed in water and may be 
examined directly in water, glycerin, or, after dehydration in alcohol, 
in oil of cloves. The tinted bacilli are made more prominent by a 
secondary staining, for a minute or two, of the red (fuchsin) prepara- 
tion in a concentrated solution of methyl-blue, the violet preparation 
being secondarily stained in a like solution of aniline brown. If the 
preparation is to be permanently preserved, it should be dehydrated 
in strong alcohol after washing in water, and it may then be treated 
with oil of cloves and mounted in Canada balsam.* 

DISEASES LIKELY TO BE CONFOUNDED WITH 
RHEUMATISM. 
Ordinarily an attack of acute rheumatism is recognized without dif- 
ficulty by the pains in the joints, their swelling and tenderness, the 
shifting character of the disorder from joint to joint, and the absence 
of the symptoms so common in continued fevers, of disturbance of the 

* Pepper's System of Medicine. Phila., 1885. Vol. I, page 102. 
5 



66 DIFFERENTIAL DIAGNOSIS. 

stomach and brain (if we except the so-called cerebral rheumatism 
which appears to be associated with a uraemic condition, if its symp- 
toms are not in reality occasioned in this way), as well as of the inter- 
missions or remissions of periodic fevers. 

Nevertheless it is true, as remarked by Dr. S. O. Habershon,* that 
while there are many characteristics of true rheumatic diseases, few 
maladies are more easily mistaken, and there is no sign which is uni- 
formly present. Pain is, perhaps, the most constant indication, with 
stiffness of one or more joints; but rheumatic pericarditis may, and 
often does, exist without any pain whatever. The same may be said 
in reference to febrile symptoms, to increase of temperature, and to 
changes in the urine; none of these signs is pathognomonic. Many 
maladies are designated rheumatic which have no connection with 
that disease. 

i. Diseases of the spine are often said to commence with an attack of 
rheumatism; but it will generally be found that the pain in the course 
of the nerves or in the fibrous tissues arises from direct implication of 
the nerves or their centres. 

2. The same remark applies to pain produced by the pressure of 
cancerous, aneurismal, or other tumors. Thus cancerous disease of 
the lumbar glands is often mistaken for lumbago; so also the pain 
from aneurismal disease of the thoracic and abdominal aorta, early in 
the disease, when no pulsating tumor can be detected, is generally 
referred to rheumatism. 

3. During the course of renal disease, abnormal irritation arises not 
only in the serous membranes, producing pericarditis, pleurisy, peri- 
tonitis, etc., but a similar change happens with the synovial mem- 
branes, and a form of disease is induced which simulates rheumatism. 

4. In chronic poisoning by lead, vague pains in the fasciae, as well 
as in the joints, have been designated "saturnine arthralgia." 

5. Periosteal disease is occasionally a source of fallacy in the diag- 
nosis of rheumatism. 

6. Shingles or herpes zoster may be found in the course both of the 
cerebral and spinal nerves; and the severe pain which precedes the 

* Half- Yearly Compendium of Medical Science. III. 



DISEASES OF THE BLOOD. 6j 

eruption of the vesicles, and which also follows their disappearance, 
closely simulates intercostal rheumatism. 

7. A more important disease, and one which is attended with fatal 
issue, is pycernia. It closely resembles rheumatism; for, with rigor 
and febrile symptoms, there is fixed pain and swelling in the joints — 
first one and then another being affected, though without subsidence of 
those parts first attacked. But while there maybe some similarity in 
the symptoms, the prognosis is widely different. The one is generally 
a curable disease, the other a fatal one. 

8. Acute synovitis closely resembles rheumatism, having pain and 
heat in the joint, with distention. But as a rule it affects only one 
joint; it is never subject to metastasis; and there is little or no effus- 
ion into the surrounding tissue. The accumulation of fluid in the 
joint is greater, but the constitutional symptoms are less prominent. 

9. Milk leg occurs after fevers, or, in women»after confinement. The 
limb swells throughout, becoming white, firm, hot and shining, and 
pits but little on pressure. The history of the case and appearance of 
the limb are usually sufficient to form the diagnosis. 

10. Myalgia (myodynia) has no essential relation to rheumatism or 
the rheumatic diathesis. The common name of muscular rheumatism 
is incorrect, for rheumatism never primarily or exclusively manifests 
itself in inflammation of muscle substance. It is a disease of nutrition, 
and not a diathetic disease,* but sometimes shows decided hereditary 
tendency. Its varieties are cephalodynia, torticollis, pleurodynia, lum- 
bago, dorsodynia, omodynia, scapulodynia, etc. Growing pains of 
childhood are of this category, and certain pains of the praecordia in 
cases of degeneration and lesions of the heart are without doubt myalgic 
in character. Pain, tenderness, and in chronic cases, spastic rigidity 
localized in certain muscles or groups of muscles without fever, or 
other obvious disturbances of the general health, are the prominent 
characters of myalgia. (Neuralgia and myalgia are contrasted later 
in this work). 

CHRONIC RHEUMATISM. 

The most common form of chronic rheumatism is that which affects 
the muscles, and it is frequently by no means easy to distinguish the 
* J. C. Wilson, Myalgia, Phila. Med. Times. Vol. xvi. p. 120. 



6S DIFFERENTIAL DIAGNOSIS. 

pains due to the rheumatic diathesis from those of a wholly diverse 
etiology. 

The principal distinctions are : 

1. From neuralgia. Neuralgic pains are usually confined to the dis 
tribution of one nerve; they are not increased by motion or pressure; 
they are not attended with diffused soreness ; and they are variable in 
intensity, and are not attended with acid secretion. The tender spots 
of Valleix may be detected along the trunk of the nerve or in its dis- 
tribution. 

2. From the pains of organic lesions. These are usually so clearly 
localized as to point to their origin. Nevertheless the pain in the right 
shoulder, symptomatic of hepatic disease, and especially of an abscess 
approaching the serous surface of the liver, and the sympathetic pain 
down the left arm in some cases of heart disease (angina pectoris), are 
often carelessly overlooked, and their significance unheeded, by class- 
ing them as rheumatic. Intercostal rheumatism has included pleurisy, 
pleurodynia, broken ribs, herpes, neuralgia, the peculiar pain, gener- 
ally of the left side, found in women and connected with menorrhagia 
and leucorrhcea; the pain on either side, which is intimately connected 
with debility and anaemia; and again it is very often confounded with 
that condition of pain and soreness of the muscle developed by over- 
work, and attended with both muscular aud cutaneous hypersesthesia, 
designated by Inman " myalgia." 

3. From the osteocopic pains of syphilis. The history of the case 
throws some light; but as this often cannot be had, it should be remem- 
bered that syphilitic periostitis evinces a decided partiality for the per- 
iosteum and shafts of the long bones, and is very generally accom- 
panied by nodes, especially in the anterior surface of the tibia, which are 
almost pathognomonic. There is often, too, a more marked cachexia 
than is found along with non-specific rheumatism. The clavicle, hum- 
erus, and forearms, are frequent locations of this form of rheumatism. 
As well as its favorite seats and accompanying nodes, there are evi- 
dences of skin and throat affections, a mutilated iris, etc., which will 
assist in forming a correct diagnosis. Furthermore, the ready response 
to a specific treatment aids in distinguishing syphilitic pains. 

4. From progressive locomotor ataxia. Ataxic patients often bitterly 



DISEASES OF THE BLOOD. 69 

complain of supposed rheumatic pains. These pains, in locomotor 
ataxy, come on in severe pangs — " stabbing, boring, shooting like 
lightning, flitting from one place to another in a very erratic manner, 
and recurring in paroxysms, lasting from a few minutes to many 
hours." Their suddenness is their especial characteristic, and should 
always put the medical observer on his guard to look out for the other 
indications, as loss of tactile sensibility, etc. These pains may be 
accompanied by a feeling of coldness, thus closely simulating some 
forms of rheumatism. The importance of them lies in the prognosis, 
as the causes of locomotor ataxy are not to be relieved by art, 
although the pains may be mitigated by anodynes and frictions. 

5. The pains of chronic renal disease often closely simulate lumbago >,, 
or muscular rheumatism of the loins. No clinical distinction can be 
positively drawn, except from examination of the urine; but, in some 
forms of renal disease albumen is often absent for long periods together. 
Moreover, the amount of the urine varies, and when great in quantity 
is usually of low specific gravity, and contains granular casts, which, 
however, are often few in number and not easily found. An absolute 
diagnosis is not always attainable. In gouty kidneys we may fall 
back upon the rational symptoms, and the distinguishing characteris- 
tics may be found to run in the following directions : Rheumatism is 
associated with the fibro-serous texture; in lithaemia the poison has 
more affinity for the true serous surfaces, and is often the cause of 
pleurisy and peritonitis. Lithaemia more affects the muscles, and 
rheumatism rather the large joints. Diarrhoea, vomiting and other 
affections of the mucous membrane, as bronchitis, accompany lithae- 
mia; and in these it diners from rheumatism. Lithaemia is accom- 
panied by headache, especially of the vertex (persistent and recurring 
vertical headache is almost pathognomonic of lithaemia), or the pain 
may be frontal. (Fothergill.) 

6. A dislocation of the shoulder has been prescribed for as " rheu- 
matism," which shows the necessity of inspection of affected joints. 

A typical effect of the acid diathesis of chronic rheumatism is the 
rheumatic markings of the teeth, to which attention has been directed 
by Dr. L. G. Noel.* 

* Nashville Journal of Medicine and Surgery, Feb., 1875. 



70 DIFFERENTIAL DIAGNOSIS. 

These markings seldom appear until after middle life is past. They 
are most frequent upon the crowns of the teeth, though they are some- 
times seen upon their buccal and labial surfaces. It is that condition 
of the teeth treated of in dental works ag "spontaneous abrasion." 

The abrasion often begins as decay in the fissures on the grinding 
surface of the molars and bicuspids, but instead of following the tub- 
uli, and dipping deep into the interior of the teeth, these become 
closed by a calcareous deposit, as fast as laid open, and the decay 
spreads out into a wide saucer-shape. This cupping out of the teeth 
is not, however, confined to the molars and bicuspids, but commencing 
upon the cusps of the canines, and cutting edges of the incisors, as 
mere mechanical abrasion, asperities disappear, the teeth become 
square and polished on the ends, and presently the surfaces begin to 
assume a concave, instead of their original convex, appearance. This 
cupping out may go on until the pulp is so nearly reached as to be- 
come irritated to the point of inflammation and death ; but usually its 
irritation is only sufficient to cause a deposition of secondary dentine 
on the interior of its chamber, a part of its substance forming a matrix, 
in which lime-salts are deposited. 

Syphilitic lesions of the teeth are best seen in the upper central 
incisors of the second dentition (Hutchinson teeth) chisel-shaped with 
cupped free border. 

Osseous lesions of inherited syphilis may be distinguished from 
those of Rickets by attention to the following points :* 



INHERITED SYPHILIS. 

The swellings, particularly those 
of the long bones, show themselves 
at or soon after birth. 



A history of syphilis or evi- 
dence* of existing syphilis in one 
or both parents. 



Preceded or accompanied by 
snuffles, coryza, and cutaneous and 
mucous lesions. 



RICKETS. 

Rarely appear before six months, 
generally still later. 



No such history necessarily. 
No such prodromata. 
*J. Wm. White. Hereditary Syphilis. Pepper's System of Medicine, Vol. ii., p. 290. 



DISEASES OF THE BLOOD. 



71 



INHERITED SYPHILIS. 

No such prodromata in most 
cases. 



Cachexia absent or moderate. 

Physiognomical peculiarities of 
syphilis present. 

Circumscribed tumors on frontal 
and parietal bones, rarely on occi- 
put. * 

Ribs not markedly affected. 

Swellings on long bones or ex- 
tremities irregular. 

Disease of ribs, when existent, 
not ordinarily coincident with that 
of other bones. 

Fontanelles close at an early 
period. 

Other syphilitic symptoms pres- 
ent, enlargement of phalanges, 
metatarsal bones, etc. 

Often accompanied by sinuses, 
synovitis, abscesses, cutaneous ul- 
cers, etc. 

Generally disappears by resolu- 
tion, without leaving any perma- 
nent change. 

Mortality among children in 
whom many bones are involved is 
very great. 

Specific treatment useful. 

In the first stage there is an ex- 
uberant calcification of the ossefy- 
ing cartilage causing necrosis of the 
new formed tissue and a consecu- 
tive inflammation, which terminates 
in the separation of the epiphyses. 



RICKETS. 

Pallor, restlessness, sweating, 
nausea, diarrhcea, etc., constitute 
a combination of symptoms which 
often precede the bone disease. 

Cachexia marked. 

Not present as a group. 

Cranial bones thickened in spots, 
usually upon occiput. 

All, or nearly all involved. 

Extremities symmetrically en- 
larged. 

Nearly always so. 



Closure delayed. 
Syphilitic symptoms absent. 



Little external or surrounding 
involvement. 



Usually leaves some bending of 
shaft and distortion of the neigh- 
boring joint. 

Much less. 



Of no benefit. 

This is less marked. There is 
formed, instead, a soft and non- 
calcified osteoid tissue. 



72 



DIFFERENTIAL DIAGNOSIS. 



GOUT. 

The signs of gout have already been in part referred to (page 60). 
It is not nearly so frequent in the United States as in England, and is 
apt, therefore, to be mistaken for rheumatism, which it closely re- 
sembles. 

The following table of differences will facilitate the diagnosis : — 



GOUT. 

Generally hereditary. 

Occurs usually in men, beyond 
middle age, rarely in women. 

Attacks generally periodic, and 
last about a week. 

The small joints chiefly affected, 
especially that of the great toe, or 
lower extremity. 

Much local pain, redness, cede- 
ma, and enlargement of veins. 

Kidneys generally affected ; lit- 
tle fever ; no sweating ; heart not 
implicated. 

Chalk stones in the joints and 
ears. 

Uric acid always present in the 
blood in large excess (Garrod). 



RHEUMATISM. 

Rarely hereditary. 

Occurs oftener In women, and 
before middle age. 

Attacks dependent on exposure, 
and last several weeks. 

The large joints are those gen- 
erally attacked. 

All these symptoms less marked. 

Kidneys not involved; fever 
often high ; sweating profuse ; 
heart often implicated. 

Chalk stones never present. 

Uric acid never found in excess. 
Increase of fibrin in the blood.* 



Dr. Garrod says that the presence of uric acid in the blood can 
readily be demonstrated by taking a fluidrachm of the serum from a 
blister, adding to it six minims of acetic acid, and placing a thread in 
the mixture. The uric acid, if present, will be deposited in fine crys- 
tals along the thread. 

*Hayem. The increase of fibrin in the blood may precede any local manifestation of 
the disease ; so that by examination of the blood at the onset of the fever one may diagnos- 
ticate the rheumatism in advance and thus prevent joint complications. — Phila. Med. 
Times, Vol. xvi., p. 504. 



DISEASES OF THE BLOOD. 73 

RHEUMATOID ARTHRITIS (RHEUMATIC GOUT, AR- 
THRITIS RHEUMATICA DEFORMANS). 

This is by no means an infrequent disease in this country, and is a 
very serious one. It is now acknowledged by the best authorities to 
be a distinct malady, different in origin, history and treatment from 
both rheumatism and gout. It is common in women and young per- 
sons, and is not produced by alcoholic or other excesses. It implicates 
joints of all sizes, and in all the extremities. They become perma- 
nently affected, stiffened and enlarged, but no deposits of urate of soda 
are found in them. The disease frequently shows itself without fever ; 
the joints swell by serous effusions into the capsules, and along with 
this the*ends of the bones enlarge. The integument is not inflamed, 
or but moderately so, and the muscles do not appear to suffer. The 
result on the joint may be subluxation, relaxation, or anchylosis. The 
concretions attendant on the disease prove, on analysis, to be of the 
same composition as bone, with a slight preponderance of lime 
(Drachmann). Phosphoric acid is diminished in the urine and in- 
creased in the blood (Bocher). 

Neither the treatment of gout nor that for acute rheumatism yields 
its usual results in this disease. 

PERNICIOUS ANEMIA AND LEUKEMIA. 

The positive diagnosis of these conditions can only be secured by a 
microscopic examination of the blood. 

In pernicious anaemia,' according to Dr. Eichhorst, the character- 
istic appearances are : A portion of the red corpuscles are seen to re- 
tain their normal size, but are marked by an extreme paleness, with a 
tendency to crenation and the formation of rouleaux, while others 
among them attract attention by their small size, which is reduced often 
to one-fourth the diameter of the well-formed corpuscles. These small 
ones are more deeply colored, and if allowed to roll over under the 
thin cover-glass, their appearance in profile shows them to have lost 
to a greater or less extent their bi-concave outline. 

Dr. F. P. Henry* has found in the blood of pernicious anaemia 

* Phila. Medical Times, April 3, 1886. 



74 DIFFERENTIAL DIAGNOSIS. 

a very interesting illustration of "tissue reversion." The red blood 
corpuscles are occasionally seen with nuclei, and resemble the corpus- 
cles of the blood of cold-blooded animals in all their principal charac- 
teristics ; namely, in " their number, their size, their shape, and the 
amount of haemoglobin they carry." 

For the examination of the blood in such investigations, Dr. Gow- 
ers, of London, recommends the use of the hemacytometer, by which 
he measures for the purpose of ascertaining the number of red and 
white cells in a given volume of blood. The essential part of the ap- 
paratus consists of a glass slip, on which is a cell one-fifth of a milli- 
metre (.008 inch) deep. The bottom of this cell is divided into one- 
tenth millimetre squares. Upon the top of the cell rests the glass 
cover, which is kept in its place by the pressure of two springs. In 
estimating the number of corpuscles, the patient's finger is pricked ; 
then by means of a capillary pipette, five cubic millimetres of blood 
are taken up and well mixed up with 995 cubic millimetres of saline 
solution ; a drop of the dilution is then placed in the glass cell, the 
cover is adjusted, and the slide is placed in the field of a microscope. 
In a few minutes all the corpuscles have sunk to the bottom of the 
cell, and are seen lying on the squares ; the number of corpuscles in 
ten squares is then counted, and this, multiplied by 1 0,000, gives the 
number in a cubic millimetre of blood. The degree of dilution and 
size of the squares are so proportioned that, with normal blood, two 
squares contain about 100 corpuscles, and the number in two squares 
thus expresses the percentage proportion of corpuscles to that of 
health. The proportion of white corpuscles to red, or their absolute 
number, may be easily determined during the same observation. The 
Globule Counter of Malassez is believed to furnish more exact results 
than that of Gowers.* 

A simpler method was used by Dr. J. G. Richardson, of Philadel- 
phia. He spread a drop of fresh blood thinly on a glass slide, letting 
it dry, and then counted the number of white corpuscles. The speci- 
mens when thus prepared can be kept dry for any length of time, if 
preserved from dust and moisture, so that by comparing specimens of 

* For a description see Archives de Physiologie for June, 1 880, or Da Costa's Medical 
Diagnosis, 6th Ed., Phila., 1884, page 752. 



DISEASES OF THE BLOOD. 75 

different persons' blood, prepared similarly, the variations in the num- 
ber of white corpuscles can be readily observed. By this means he 
claimed to be able to detect leukaemia in its early stages. 

Profound anaemia is met with in the following conditions: (i) After 
great loss of blood or exhausting discharges; (2) where there is inan- 
ition (insufficient nourishment); (3) in chlorosis; (4) in malignant dis- 
ease; (5) in Bright's and Addison's disease; (6) leucocythemia ; (7) 
chronic metallic poisoning, and (8) in malarial toxaemia. 

The symptoms of the idiopathic or " progressive pernicious" form 
of anaemia are described by Dr. Byron Bramwell, as follows : A pro- 
found anaemia, which is associated with marked changes in the micro- 
scopical characters of the blood, and (in most cases) with the presence 
of retinal hemorrhages. The patient is generally well covered with fat, 
the skin is smooth and soft, the face looks slightly swollen, and is of a 
pale yellow or yellowish-green color. All the symptoms of profound 
anaemia are present, viz., extreme pallor of the mucous membrane, 
great debility, tendency to fainting, dyspnoea and palpitation on exer- 
tion, buzzing in the ears, headache, subcutaneous oedema, etc.; loud 
blowing murmurs are heard over the heart and great vessels; there is 
a venous hum in the neck ; the pulse is very soft and compressible. 
Attacks of vomiting and diarrhoea are frequent ; irregular elevations 
in temperature, transient paralyses, hemorrhages from the mucous 
membranes, occasionally occur. The causes of the disease are at pres- 
ent unknown. The disease is said to occur more frequently in women 
than in men. In the majority of cases the termination is in death, the 
end being ushered in by profuse diarrhoea, coma, or delirium. The 
diagnosis is facilitated by examination of the blood.* 

Great advances have been made within a few years in the depart- 
ment of microscopic botany, and sufficient evidence has been accumu- 
lated from experiment and observation, to warrant the statement that 
many diseases both in man and the lower animals are due to infection 
by micro-organisms, termed collectively microbes (niicrobies) by Pas- 
teur. The methods pursued in studying this interesting and very im- 
portant question of the relation of these organisms to disease, are of 

*See article on Diagnosis of Progressive Pernicious Anaemia, by Dr. F. P. Henry, 
Phila. Medical Times, vol. xvi., page 499. 



/6 DIFFERENTIAL DIAGNOSIS. 

three kinds, viz. : (i) By microscopic manipulation (behavior to cer- 
tain reagents and coloring fluids, etc.); (2) By isolation and culture of 
the morbid agent (on gelatine, agar-agar, peptone, and in various 
other media); and (3) By inoculation of the pure cultures, or the se- 
cretions obtained originally from typical cases of disease. 

It has been found that suppuration is due to the presence in the tis- 
sues of three varieties of staphylococcus pyogenes (aureus, citrus, or 
albus) and the streptococcus pyogenes. In septicaemia in man, Klein 
has found in the blood-vessels of the swollen lymphatic glands, large 
numbers of minute bacilli slightly thicker, but otherwise resembling 
the organisms claimed by Koch as the cause of septicaemia in mice. 
These organisms do not originate within the body, but are introduced 
fro*n without (infection), hence the explanation of the care used to 
keep wounds clean in the antiseptic dressings; precautions which are 
fully justified by the wonderful achievements of modern surgery. 

Among internal diseases, relapsing fever has been long known to be 
accompanied by a spirillum in the blood, as pointed out by Ober- 
meyer in 1873. It is the only form of spiro-bacterium which is known 
to be pathogenic to man; all the others belong either to the class of 
micrococci (round bodies) or bacilli (rod-shaped bodies). Micrococci 
have* been found in the pus of open wounds, and in closed abscesses 
as well, occurring singly and in chains or zooglceic masses. In all 
cases of diarrhoea, the discharges from the bowels swarm with micro- 
cocci, and in typhoid fever they are also found colonized in the ulcers 
and also in the neighboring mesenteric glands. Wassilieff has shown 
that these micrococci only occur after the death of the tissue or tis- 
sues, so that in these they may multiply so as to form extensive col- 
onies, and that therefore the presence of these micrococci is only a 
secondary phenomenon.* 

Micrococci also occur in tuberculosis, and in severe' catarrhal pneu- 
monia, presenting a close analogy between these diseases and pleuro- 
pneumonia of cattle or the pneumonia of swine fever. Micrococci are 
also found in normal human saliva, and Sternberg considers that they 
are the active agents in causing septicaemia when saliva-injections are 
made into rabbits, but this is not considered as proved.f 

* Centralblatt ficr die Med. Wissen. 1 88 1. 

f Klein. Micro- Organisms and Disease. London, 1884. 



DISEASES OF THE BLOOD. 77 

On the other hand, Chauveau, Cohn, Weigent, Pohl-Pincus and 
others have apparently shown that the morbific agent in small-pox 
and in vaccinia is a micrococcus; Fehleisen claims that erysipelas is 
due to the micrococcus erysipelatosus , while Buhl, Huter and Oertel 
claim that the micrococcus diphtheriticus is the cause of the manifes- 
tations of diphtheria. This, however, has been denied by Wood and 
Formad, who see nothing specific in the micrococcus found in the grey 
pseudo-membrane of diphtheria. Neisser has detected a micrococcus 
gonorrhoeae which has been called for brevity rather than elegance, a 
"gonococcus." Similar organisms have been found in ulcerative 
endocarditis, in scarlatina, and in puerperal fever. Frankenhauser 
discovered a micrococcus in the blood of pregnant women suffering 
with pernicious anemia; Aufrecht describes them as occurring in 
syphilitic mucous patches; Schuler and Rosenbach, in the lesions of 
acute infectious osteo-myelitis ; but their specific differences, if they 
exist, as well as distinguishing characteristics, remain to be definitely 
defined. 

L. Domingos Freire ascribes yellow lever to the micrococcus 
xanthogenicus, and he has made an extended series of inoculation ex- 
periments for the prevention of the disease, with reported success. 
Dr. Carmona, of Mexico, also claims similar success, but it is too 
early to decide either upon the active agent or the accuracy of the 
reports which have been made. 

Bacilli present more distinctive forms and are more susceptible to 
investigation. The pathogenic forms in man are numerous. The 
bacillus septicaemia of Klein has been already referred to. Klebs 
and Eberth claim that in the bacillus typhosus exists the infective 
principle of typhoid fever. The bacillus malaria of Klebs and Tom- 
masi Crudelli has been further investigated by Laveran, and the 
opinion of more recent investigators is that the " malarial body " is less 
a bacillus than an infusorian.* 

Armauer Hansen (Virchow's Archiv. B. lxxix.) first ascertained 
the existence of a peculiar bacillus in the large leprosy cells of Virchow, 
which has been named the bacillus lepra. The Bacillus anthracis 

* See page 46 for fuller consideration of the relation of this to malarial toxaemia. 



-8 



DIFFERENTIAL DIAGNOSIS. 



occurs in charbon or wool-sorter's disease i Davaine, Bollinger, Koch 
and others). 

Koch finds in the bacillus tuberculosis the efficient cause of all 
tubercular lesions.* Similar elements have been found in tuberculosis 
of the ipus). Comma shaped bacilli are declared by Koch to be 

the cause of cholera, but his conclusions are still under discussion, and 
some of his statements are contradicted by other investigators who 
are now engaged in studying this important subject. 

The purulent joint inflammation with metastatic abscesses and re- 
peated chills of pyaemia will prevent its being taken for rheumatism. 
Gonorrhceal rheumatism is regarded as a mild form of pyaemia. The 
distinction usually observed between pyaemia and septicaemia is based 
upon the following differences : + 



PYEMIA. 

Commonlv commences with a 
chill. 

Fever variable, but rarely en- 
tirely intermits. 

Sudden and great changes in 
temperature, followed by profuse 
perspiration. 



SEPTICEMIA. 



commences without 



Pulse variable; toward the fatal 
end, rapid, feeble, and irregular. 

Fades, at the beginning flushed 
or pallid, toward the end, careworn. 

Tongue smooth, dry, and exces- 
sively re'd; later brown, and even 
the teeth covered with sordes. 

Diarrhoea, with stools of a pappy 
consistence. 

*For method of staining, etc., see page 65. 
i B, A. Watson, article on Pvaemia and Se 



Commonly 

a chill. 

Fever steadily increases, but is 
lower in the morning. 

The temperature is high at the 
beginning of the disease, increases 
usually near the fatal termination, 
when it falls below the normal. 
The skin is moist, but without 
profuse sweating. 

Rapid and gradually increases 
in frequency toward the latter end. 

Expressive of a dull, listless con- 
dition throughout the whole course 
of the disease. 

Tongue, lips, and throat dry at 
the commencement ; toward the 
end, moist. Thirst is marked. 

Rice-water evacuations, very of- 
fensive; obstinate vomiting. 



pticsemia. in Pepper's System of Medicine. 



DISEASES OF THE BLOOD. 



79 



PYEMIA. 

Epistaxis. 

Mild delirium towards the fatal 
end. 

Aphthae in the mouth and throat, 
sudamina, vesicles, pustules, and 
purpuric patches. 

Pus and blood contain globular 
bacteria. 

Secondary wound complication 
rarely develops before second week 
after receipt of injury. 

Increased coagulability of the 
blood. 

Metastatic abscesses common. 



SEPTICEMIA. 

Epistaxis rarely occurs. 

A lethargic condition from the 
beginning, increasing toward the 
fatal end. 

Icteric hue of conjunctivae; sin- 
gultus often present. 

Secretions and blood contain red 
bacteria. 

Primary wound complication 
generally developed within forty- 
eight hours. 

Diminished coagulability of the 
blood. 

Complete absence of purulent or 
ichorous deposits in unmixed sep- 
ticaemia. 



PART II 



LOCAL DISEASES. 



CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM. 

Contents. — Cerebral Disorders — Congestion — Ancemia — Apoplexy — 
Thrombosis — Embolism — Meningitis — Tubercular Me ningitis — Rheu- 
matic Meningitis — Acute Cerebritis — The Ophthalmoscope in Nervous 
Disorders — Headache — Chronic Cerebral Disorders — Hypertrophy — 
Hydrocephalus — Brain Tumor — White Softening — Abscess — Chronic 
Meningitis — Thrombosis — Sclerosis — Localization of Brain Disease — 
Lesions of Cerebral Cortex — Brain Lesions other than Cortical — Tab- 
ular View of Paralysis with Seat of Lesion — Spinal Disease — Orga?iic 
and Functional Paraplegia — Diagram of Spinal, Inflammatory and 
Degenerative Diseases — Tabular View of Spinal Paralysis, Congestion, 
Meningeal Apoplexy, Spinal Apoplexy, Acute Primary Myelitis — 
Co7nparison of Acute Spinal Disorders — Tumors — Tremors — Chronic 
Degenerative Diseases of the Cord — Prof Charcots Diagnostic Chart 
of Cerebro-Spinal Affections — Patellar -Tendon Reflex of Westphal — 
Analysis of Symptoms of Focal Lesions of the Cord powers, Charcot, 
and Frb) — Comparative Semeiology of Cerebro-Spinal Sclerosis, Par- 
alysis Agitans, and Locomotor Ataxia — Paraplegia from Reflex Irri- 
tation and Myelitis Compared — Gowers' Classification of Spinal Lesions 
— Pseudo- Hypertrophic Paralysis — Lead Palsy — Hysterical Paralysis 
— General Paralysis of the Insane — Spinal Irritation, and Spinal 
Weakness — Hysteria and Hystero-Epilepsy — Neuralgia — Insanity, Its 
Different Forms, their Pathology and Etiology. 

Recent advances in the physiology of the nervous system have 
thrown much light upon mental and nervous manifestations; and many 
6 (81) 



82 DIFFERENTIAL DIAGNOSIS. 

conditions which had been hitherto regarded as primary have been 
shown to be in reality symptomatic and secondary to definite morbid 
changes occurring either in the central nervous system, the trunks of 
the nerves, or in the peripheral terminations. It is evident that dis- 
eases having their origin or seat of lesion in the nervous system will 
vary in their symptoms with the locality of the morbid process and the 
function of the part affected. Disorders of intellection and insanity 
result from involvement of the cerebral hemispheres, especially of their 
anterior portion, with impairment of special senses, and paralysis of 
parts supplied by cranial nerves, occurring with or without loss of 
power in the extremities. Diseases of the spinal cord give rise to par- 
alysis of muscles having direct connection with the seat of lesion, and 
also to disorders of sensation and nutrition. Hemiplegia may be of 
cerebral origin; paraplegia is generally spinal. Pressure or irritation 
of nerve trunks may cause local palsy, spasmodic affection, or neural- 
gia, while myopathic paralysis (such as encountered in lead palsy, 
pseudo-hypertrophic paralysis, and progressive muscular atrophy) may 
be due to a peripheral nervous affection. Hysteria, vertigo, neuras- 
thenia and some mental disorders, being of uncertain seat and unknown 
relations, may be provisionally considered as functional disorders of 
the nervous system. 

The principal symptoms referable to the brain may be considered as 
being caused by (a) congestion, anaemia, apoplexy, thrombosis, embol- 
ism, brain tumor, cerebritis and abscess; (b) by influence upon the 
brain disease of neighboring 'structures, such as meningeal inflamma- 
tion, hemorrhage, effusion or neoplasm, necrosis, disease of the middle 
ear; and by (c) poisoned conditions of the blood, as in uraemia, alco- 
holism, and the delirium of fevers. An irregular and abnormal distri- 
bution of the blood supply may give rise to night terrors, epilepsy, 
syncope, temporary (functional?) paralysis, cerebral exhaustion, 
migraine, aphasia, aphemia and agraphia; and irregular motor dis- 
charges from the cerebral centres are directly associated with chorea, 
tremor, and epileptiform convulsions ; the higher mental powers being 
apparently merely held in abeyance in catalepsy, trance and hysterical 
coma. 

Passing to the diagnosis of the principal cerebral disorders, the fol- 



DISEASES OF THE NERVOUS SYSTEM. 



83 



lowing points are of importance in distinguishing cerebral congestion 
and cerebral anaemia: 



CEREBRAL CONGESTION. 

Severe, throbbing and diffused. 

May be absent. 

Full, throbbing, tortuous and dis- 
tinct. 

Pulse full, tense ; often signs of 
plethora. 

May be rumbling or singing. 

Hallucinations ; may have active 
delirium. 

Surface temperature of scalp may 
be increased. 

Contracted. 

Not increased; may contain 
urates and phosphates (Hammond). 



CEREBRAL ANEMIA. 

Headache. Less sharp, generally vertical. 

Vertigo. Usually a marked symptom. 

Temporal Not prominent. 

Vessels. 

General Pulse irritable, often anaemic 

Circulation. murmur of pulmonary artery. 

Tinnitus Noises may be short and high- 

aurium. pitched. 

Mental Below normal ; incapacity for 

Phenomena. continual mental application. 

Temperature. Surface temperature, if at all 

affected, is diminished. 

Pupils. Dilated. 

Urine. Limpid, and may be passed in 

excess : decrease of salts. 



Cerebral exhaustion is sometimes so marked as to produce coma, 
and thus form a variety of apoplexy, and its diagnosis is made by ex- 
cluding hyperaemia, hemorrhage, embolism and thrombosis of basilar 
artery. Where the latter condition terminates in recovery, it is almost 
identical in its manifestations ; indeed, " it would be difficult to disprove 
the assertion that cases of cerebral exhaustion belong in this cate- 
gory" (Flint). 

A sudden attack of coma in a case of albuminuria may be set down 
as due to urcemia, if embolism and apoplexy are excluded (by noting 
the absence of hemiplegia). Should the coma be associated with 
epileptiform convulsions, this diagnosis is likely to be correct, even if 
no albumen can be detected in the urine; since the form of renal dis- 
ease most likely to give rise to uraemic poisoning is the cirrhotic form 
(contracted kidney), in which the albumen may be absent from the 
urine for considerable periods of time. 

The early diagnosis of diseases attended by coma is of great import- 
ance, with the view of promptly instituting proper treatment. 



S4 DIFFERENTIAL DIAGNOSIS. 

CEREBRAL APOPLEXY. 

Apoplexy must be distinguished from drunkenness, narcotic poison- 
ing, uremic poisoning, epilepsy, concussion of the brain, cerebral 
thrombosis, embolism, and insolation or sunstroke. 

Drunkenness. The odor of liquor may excite suspicion. If the 
patient vomit, the ejecta may be tested for alcohol. Or the urine may 
be examined by Anstie's test, as follows : — 

&. Bichromate of potash, I part 

Strong sulphuric acid, 300 parts. Mix. 

To fifteen minims of this add a few drops of the urine, and if the 
patient has taken a toxic dose of alcohol, the mixture will turn an 
emerald green. In drunkenness, the pulse is generally rapid, the 
pupils not dilated, the eye injected. The patient can be roused, and 
hiccoughs. 

A modification of this test, introduced by Woodbury, is to put in a 
small test-tube a cubic centimetre of colorless sulphuric acid, and add 
an equal quantity of urine, so as to form a layer of urine over the acid. 
A crystal of bichromate of potassium is now added, and the liquid 
slowly mixed by rotation. If a proportion of alcohol amounting to 
three parts in a thousand be present a bright green color will be formed, 
otherwise the solution remains a light red color. 

Dr. MacEwan, of Glasgow, gives the following method of distin- 
guishing alcoholic coma from that of apoplexy, fracture of the skull, 
and other causes. In alcoholic coma, as long as the patient is undis- 
turbed the pupil is contracted ; but if any stimulus not sufficient to 
arouse the patient be applied to him, such as a shake or a pull of the 
beard, the pupil dilates, only, however, to become contracted again as 
soon as the person is left at rest* 

Narcotic poisoning. In this condition the outset is gradual ; there are 
often convulsions, but the patient may be roused. In opium poison- 
ing the pupil is extremely contratcted ; so it is in hemorrhage in the 
pons. The vomiting, the acrid odor of opium, and the gradual inten- 
sification of the coma, are diagnostic. There is no hemiplegia. 

Urcemic poisoning. Here the coma nearly always comes on grad- 

* British Medical Journal, November 16, 1S78. 



DISEASES OF THE NERVOUS SYSTEM. 85 

ually and is preceded by general convulsions. It is not deep, and at 
first the patient may be aroused. The stertor of the breathing is more 
superficial, while there is also frothing at the mouth. 

Nearly always, distinctive modifications of the heart-sounds will be 
heard, as reduplication of one or both, intensity of second sound, etc.; 
while there are elevation of the arterial tension and increased cardiac 
impulse. Of these cardiac physical signs none seem so constant or 
remarkable as muffling of the first sound. (Mr. W. Whittle.) 

There are, moreover, in many cases marked prodromata. The skin 
has been waxy and cedematous, the eyelids puffed, and the legs and 
feet swollen. The urine may or may not be albuminous (but albumen 
may also be present in apoplexy). 

Epileptic coma presents a history of convulsions ; lasts but for an 
hour or two; there is frothing at the mouth; and the temperature is 
elevated. 

In hysteria and catalepsy there is no alteration of temperature, and 
no frothing at the mouth. 

In concussion or compression from injuries to the head, the skin is 
pale, the pupil dilated, and vomiting occurs. The symptoms are usu- 
ally of short duration, and there is usually a history of injury. Men- 
ingeal hemorrhage from injury presents no points of difference from 
true apoplexy, except that hemiplegia is generally Wanting (Flint). 

Syncope is readily distinguished by the feeble pulse, the pale face, 
the quiet respiration, and the brief duration of the unconsciousness; 
while in asphyxia the livid face, distressed breathing, and blue lip, 
which precede the coma, indicate its distinction. 

REFLEX HEMIPLEGIA. 

The details of a case are given in abstract in the Practitioner from 
M. Barbez, who reports it in the Revue de Medecine for June, 1886, in 
which five weeks after the evacuation of a highly-offensive empyema 
the patient became suddenly paralyzed in the right arm, with aphasia, 
and continued for more than two months in this condition, with mild 
delirium. There were some spasms of the affected arm. 

Especial attention is attracted to the case by the explanation which 
is given of the connection between the two conditions. M. Luys con- 



86 



DIFFERENTIAL DIAGNOSIS. 



sidered it a case of limited left lateral meningitis. But M. Barbez 
classes it among so-called reflex hemiplegias, cases of which have been 
reported by several writers. The explanations seem very far-fetched 
to us. As the patient had a good ground-work for pyaemia, we would 
rather suppose that his brain-trouble was of septic origin, probably 
embolic. 

In regard to thrombosis and embolism of the larger cerebral vessels, 
the diagnosis is often extremely difficult. The following table of the 
comparative symptoms is drawn up from the works of Buduy, Gelpke, 
Flint, and Hamilton : 



CEREBRAL HEMORRHAGE. 

Occurs most frequently in 
advanced age, with atherom- 
atous arteries. 



Onset generally sudden. 

Hypertrophy of left ven- 
tricle. Alcoholism, or other 
debilitating habits. 



Pain in the head. 

Ataxic aphasia, secondary 
to loss of consciousness. In- 
telligence much affected. 

Often coma. 



Paralysis very marked ; oc- 
curs on either side. 



Apoplectic phenomena 
from the outset. Symptoms 
of cerebral pressure. 

Disappearance of the resi- 
dual disorder after a moder- 
ate time. May terminate in 
chronic abscess. • 

After a few days pain in 
the head and increased tem- 
perature of the body on the 
unaffected side (Flint). 



CEREBRAL THROMBOSIS. 

In advanced age. May 
occur in children during 
scarlet fever and renal dis- 
ease. 

Development of symptoms 
gradual. 

No rheumatic history. En- 
darteritis deformans of peri- 
pheral arteries sometimes 
present. 



No headache. 

Aphasia incomplete and 
primary, occasionally absent. 
Intelligence less involved. 

Rarely loss of conscious- 
ness. 

Paralysis less marked. 



No apoplectic phenomena 
at onset. 



Recovery slow; more or 
less hemiplegia may remain. 



May have oedema more 
marked on affected side. 



CEREBRAL EMBOLISM. 

Almost always in early or 
middle life (Flint). 



Onset rapid, without pre- 
monition. 

Previous articular rheuma- 
tism or other diseases leading 
to formation of clots. Often 
cardiac valvular insufficiency. 
Coincident embolisms are 
sometimes present elsewhere 
in the body. 

No headache. 

Amnesic aphasia. Reten- 
tion of mental power. 

No coma. 



Muscular paralysis exten- 
sive ; nearly always on the 
right side (Flint). 

Early apoplectic phenom- 
ena, but without loss of con- 
sciousness. 

Very rapid, or else quite 
imperceptible disappearance 
of the residual disorder. May 
be followed by softening. 

One-sided oedema, often in 
the arm alone. 



DISEASES OF THE NERVOUS SYSTEM. 



87 



The high temperature (108 to 113 F.) of cases of sunstroke serves 
to distinguish such from the coma of apoplexy; although in some 
cases of insolation the coma is probably due to cerebral exhaustion 
without high bodily temperature, the distinguishing features of which 
have been previously considered. The subjects attacked are gener- 
ally laboring men, who have been exposed, while at their work, to a 
continuous high temperature. 

ACUTE CEREBRAL INFLAMMATION. 
Considering the acute inflammatory state of the brain and its cov- 
erings, we tabulate their comparative semeiology as follows : 



SIMPLE MENINGITIS. 

(Lepto-meni?igitis. ) 

Due to disease of 
the cranial bones, 
traumatism, exposure 
,to sun. (Very fre- 
quently the meningitis 
of young adults has a 
syphilitic source.) 
May be epidemic. 

A disease of both 
infants and adults, 
though usually in the 
latter. 

Previously healthy; 
no prodromata. 



No chest symptoms. 
Onset sudden. 



Headache intense 
on both sides of head. 

Pupils contracted. 

Intelligence clear 
at first, but may be- 
come furiously deliri- 
ous. 



TUBERCULAR 
MENINGITIS. 

Scrofulous inherit- 
ance. 



Often children un- 
der five years of age. 



History of persist- 
ent headache and ob- 
stinate constipation ; 
wasting. 

Previous pulmon- 
ary trouble. 

Takes four or five 
days to develop; ap- 
proach insidious. 

Persistent and 
marked headache, 
which exacerbates. 



Pupils 
dilated. 



irregularly 



Delirium of low 
grade at night (stu- 
por in second stage) ; 
strabismus, and oscil- 
lation of eyeballs. 



RHEUMATIC 
MENINGITIS. 



Rheumatic history 
or diathesis. 



Adults. 



Often during an at- 
tack of joint inflam- 
mation. 



None. 



Rapidly developed. 



Intense pain. 



Leads to active de- 
lirium. 



ACUTE CEREBRITIS 

AND CEREBRAL 

ABSCESS. 

May be due to gen- 
eral causrs, such as 
pyaemia, etc., or to 
local causes, as trau- 
matism, bone disease, 
local irritation, exten- 
sion from meninges, 
etc. 

Often in elderly 
subjects. 



Rarely occurs in 
previously healthy 
persons. 

None. 



Slow, and may sim- 
ulate typhoid. 

Dull, persistent and 
localized; less than 
in meningitis. 



Mental confusion 
and impairment of in- 
telligence. 



ss 



DIFFERENTIAL DIAGNOSIS. 



SIMPLE MENINGITIS. 

(Lef>to-meningiiis.) 



TUBERCULAR 
MENINGITIS. 



RHEUMATIC I ACUTE CEREBRITIS 



Vomiting early, fre- Vomiting occasion- 
quently. , ally. 

Pulse full and rapid. Irregular and slow- 
pulse. 



MENINGITIS. 

Not marked. 

Pulse full and rapid . 



High fever. 



Fever not intense. 



Temperature 
be very high. 



may 



Convulsions early, Convulsions late, 

contracted pupils, with with dilated pupils 

contractions of flexor and hemiplegia. 
muscles of arm or leg. 

In fatal cases death Lasts from one to 
generally occurs in a three weeks. 
week; recovery is 
slow. 

Prognosis favorable Prognosis unfavor- 
under prompt treat- able, 
ment. 



No convulsions. 



AND CEREBRAL 
ABSCESS. 

Vomiting not in- 
frequent. 



Less fever. 

No convulsions ; 
but sudden hemiple- 
gia may occur. 



Lasts a few days ; 
death often occurs 
from continued high 
temperature. 

Prognosis fair. 



Course 
chronic. 



Prognosis 
couraging. 



often 



Dr. Gee notes that meningitis of the base of the brain is generally 
tubercular; and when tubercular meningitis attacks the convexity, 
there is a constant convulsive condition, moderate force and very vari- 
able pulse. (See page 52 for a more detailed account of tubercular 
meningitis.) 

These cerebral diseases may be distinguished from typhoid fever by 
the history and course of the affection. Typhoid occurs in the spring 
and fall, and is often endemic; it rarely appears in children, and gener- 
ally attacks young adults. It is a continued fever, coming on in a 
hitherto healthy person with malaise, epistaxis and diarrhoea. Chills 
and vomiting are rare. Convulsions and paralysis, if they occur at 
all, are late manifestations, and due to complications. Delirium is of 
low type, headache dull, moderate deafness, pulse rapid but regular or 
dicrotic. Abdominal symptoms generally prominent, tympanites, diar- 
rhoea, tenderness and gurgling on pressure in the right iliac fossa, and 
a discrete rose-colored eruption upon the chest and belly. Convales- 
cence at the beginning of the third week; disease generally continues 
about four weeks. 



DISEASES OF THE NERVOUS SYSTEM. 89 

THE OPHTHALMOSCOPE IN NERVOUS DISORDERS. 

In the diagnosis of intracranial disorders the ophthalmoscope is often 
of great service, though, perhaps, scarcely to the extent advocated by 
Bouchut. The discrete tubercles of the choroid accompanying meningeal 
deposit, the choked disc in cerebral tumors and inflammations, and the 
retinitis and retinal hemorrhages of Bright's disease are of great import- 
ance. Bouchut declares* that the ophthalmoscope is as indispensable 
to the physician as to the oculist, and he was among the first to point 
out the great importance of this aid to practical medicine. We quote 
his opinions and conclusions: 

"All diseases of the brain and spinal cord, and all the nervous affec- 
tions termed neuroses, because they are regarded rather as functional 
than organic, ought to be investigated by its aid. When by its assist- 
ance the physician discovers a lesion of the optic nerve, of the retina, 
or of the choroid, in a case presenting convulsive, choreic, paralytic, 
or spasmodic nervous phenomena, he may be certain that a cerebro- 
spinal lesion is the starting point of these symptoms. Every symptom 
regarded as nervous, which is accompanied by a lesion of the fundus 
of the eye, is caused by an organic alteration of the brain, the cord, or 
the membranes. Thus is it with chorea, considered by many physi- 
cians as a simple neurosis; and yet this should, in consequence of the 
congestive optic neuritis found in its subjects, be regarded as a conges- 
tive affection of the anterior spinal columns. So also epilepsy, in a 
certain number of cases, is the result of cerebro-spinal lesions which at 
the same time induce changes in the optic nerve or retina. Hysterical 
paraplegia and paralysis produce no neuro-retinian changes, while 
symptomatic paraplegia and spinal ataxia produce either simple hy- 
peremia of the optic nerve or hyperemia and atrophy. So leucaemia, 
tubercular, glycosuric, or albuminuric diathesis are often revealed by 
optic neuritis, the ophthalmoscopic diagnosis in some of these cases 
being most striking. It is especially in patients attacked by general 
acute tuberculosis, accompanied by typhoid symptoms, and which are 
mistaken for typhoid fever, that cerebroscopy becomes truly remarka- 
ble. In an infant in whom the disease had all the appearance of 

*" Revue Cerebroscopique," in Gazette des Hopitaux, for January, 1874. 



90 DIFFERENTIAL DIAGNOSIS. 

typhus, the ophthalmoscope, by revealing tubercles of the choroid with 
neuro-retinitis, determined that there were tubercles in the brain, and 
consequently productions of the same character all over the body — 
which the autopsy demonstrated to be the fact. 

" Can any diagnosis be more exact than this ? You see, in the liv- 
ing man, tubercles of an organ which permit you to conclude that they 
will also be found elsewhere. You see a nerve either healthy or dis- 
eased, and this indicates whether its roots are sound or diseased ; and 
you have almost laid bare arteries and nerves which are so afferent to 
the brain that changes in them, studied with care, represent similar 
changes in a portion of the nervous centres. It seems almost marvel- 
ous ; and I do not think that since auscultation there has been any- 
thing discovered so useful to semeiology. Henceforth, the physician 
may divine and often affirm lesions of the brain, cord, or meninges, 
the diagnosis of which before was impossible or only probable. Thus: 
I. From hyperaemia and hyperaemic tumefaction of the optic nerve 
there results the diagnosis of mechanical or inflammatory hyperaemia 
of the brain in meningitis, in cerebral hemorrhage, effusions into the 
brain, and in some cases the diagnosis of ataxic or other spinal dis- 
eases. 2. By papillary oedema joined to hyperaemia I recognize 
oedema of the meninges ; or an obstructed cerebral circulation through 
meningitis, cerebral tumors, ventricular hydrocephalus, cerebral hem- 
orrhage, meningeal effusions, thrombosis of the sinus, etc. 3. By 
neuro-retinian and choroidean anaemia, I recognize cerebral hemor- 
rhage of ramollissement, and if the anaemia be absolute it is fatal. 
Empty arteries and veins of the eye, and an exsanguineous condition 
of the choroidean network, indicate arrest of cerebral and cardiac cir- 
culation. 4. By exudative and fatty optic neuro-retinitis, I recognize 
chronic meningo-cephalitis ; the encephalitis of cerebral tumors, and 
the changes in the nervous substance which accompany these tumors. 
5. By retinian varices and thromboses, I distinguish meningeal throm- 
boses, or those of the sinuses. 6. By the aneurisms of the retinian 
arteries we may recognize the miliary aneurisms of the brain. 7. By 
simple retinian hemorrhages we recognize a compression of the brain 
by hemorrhagic or other effusions ; but if these retinian hemorrhages 
are accompanied by retinian steatosis, there is also cerebral steatosis, 



DISEASES OF THE NERVOUS SYSTEM. 9 1 

and this is the case in chronic albuminuria, leucocythsemia, and glyco- 
suria. 8. By atrophy of the optic nerve, tumors of the brain and cer- 
ebral or spinal sclerosis are discovered. 9. Finally, we never meet 
with tubercular granulations in the choroid without the existence of 
similar ones in the lungs or other organs."* 

The ophthalmoscope is now frequently employed for diagnostic 
purposes in ordinary medical practice where there is imperfection of 
vision, to determine whether it is due to other than nervous lesions, to 
discriminate between affections of different portions of the eye, and, 
sometimes, to measure the amount of refraction in cases of hyperme- 
tropia and myopia. Even where there is no impairment of sight, 
there still may occur very decided and characteristic retinal changes 
and alterations in the optic disc, which are readily detected by oph- 
thalmoscopic examination, as already indicated ; so that in obscure 
cases the routine examination of the eyes has become nearly as im- 
perative as the chemical and microscopical examination of the urine. 

HEADACHE. 

Some of the most trying cases to treat are those of headache, be- 
cause this symptom may appear in many and even diverse morbid 
states, and often indicates serious cerebral disorder. Mr. Wm. Henry 
Day, of London, f has made a study of these conditions, and thus 
summarizes his conclusions : — 

Headache usually denotes some functional disturbance of the brain 
or its membranes, induced (1) by excess of local blood pressure, (2) 
by absorption into the blood of poisonous matters, (3) or by such a 
diminution of healthy blood as provokes irritation and suffering. It 
may be a symptom of organic disease, either of the brain or its mem- 
branes, or of the kidneys or stomach, and uterus. 

Cerebral ancemia. — A striking symptom is pain at the top of the 
head, which often feels hot and burning, sometimes gnawing and 
scraping. Irritability of temper. Face livid and cold. Patient easily 
exhausted. Eyes dull. 

Hyperemia, Active or Passive. — Active. — Arterial fullness. Head hot, 

* Medical Times and Gazette, January 23, 1875. 
f British Medical Journal, Nov. i6lh, 1878. 



92 DIFFERENTIAL DIAGNOSIS. 

pain frontal, throbbing and bursting, pulse tense, full. Conjunctivae 
reddened. Eyes bright. Photophobia. Mentality dull. Apoplexy 
may ensue. 

Passive. — Venous fullness from obstruction caused by heart disease, 
bronchocele, etc., pleuritic effusion, defective ventricular action. 

Sympathetic headache. — Faulty digestion or ovarian excitement. 
Stomach sometimes weak and over-sensitive. Catamenial headache. 
Dyspeptic and bilious headache. Irritation of the sympathetic reduces 
the amount of blood in the brain. 

Nervous headache. — Disturbance of brain from overwork, worry and 
anxiety. Aggravated by some of the circumstances favoring sympa- 
thetic headache. In women there is a passage of a large quantity of 
limpid urine; feet and hands cold. Confusion of ideas. Nausea and 
sickness, not attributable to errors in diet, may precede the attack. In , 
nervous people constipation may cause headache. 

Poor seamstress headache. — Spanaemia. Headache of excessive men- 
struation, or menorrhagia. Hereditary influence strong. 

Neuralgic headache. — From decayed teeth, peripheral irritation, ma- 
larial poison. Pain and tenderness along the fifth nerve. Pain 
intense; not relieved by vomiting. 

Toxcemic. headache. — Poisoned blood acting on nerve centres, from 
particular articles of food or drink, and drugs. Or certain specific 
diseases — gout, rheumatism, and syphilis. Headache of vitiated 
atmosphere. Tea or coffee headache. 

Organic headache. — Morbid growths ; meningitis. When slowly 
progressing pain is limited to smaller area, and is intense. Periosteal 
inflammation is accompanied by tenderness upon pressure. 

Headache in children, due to accidental injuries, to derangement of 
alimentary canal, anaemia, exhausting influences, such as bad food and 
impure air, immoderate intellectual efforts, and sometimes to organic 
diseases (often tuberculosis). 

In strumous and weakly children headache must be carefully 
watched. A headache of long standing in a child is significant, and 
requires more serious attention than in the adult. 



DISEASES OF THE NERVOUS SYSTEM. 



93 



CHRONIC CEREBRAL DISORDERS. 
In children the diagnosis may be required to be made between hy- 
pertrophy of the brain and hydrocephalus, which have enlargement of 
the head as a common sign. 



HYPERTROPHY. 

Increase in size most marked 
above the superciliary ridges. 

Head square in shape. 

No yielding of fontanelle on 
pressure. 

Eyes at normal distance. 

Excessive amount of brain, es- 
pecially white matter. 

Patient dull, liable to epileptic 
fits, and suffers from headache. 



HYDROCEPHALUS. 
Increase in size most marked at 
the temples. 

Head more rounded. 
Fontanelle elastic. 



Distance between the eyes in- 
creased. 

Excessive amount of fluid in 
ventricles, or sub-arachnoid space. 

Mentality feeble; generally can 
be traced to congenital source ; 
death may occur from convulsions. 
No marked headache. 



The diagnosis of hydrocephalus may be confirmed by tapping the 
fontanelle with the aspirator, or a hypodermic syringe. In adults 
brain tumor and sclerosis are among the prominent disorders of slow 
progress, the symptoms varying in a very marked manner with the 
location of the lesion. Chronic inflammation of the brain may termi- 
nate in insanity or in abscess. In its course it has been mistaken for 
dyspepsia, but a proper inquiry into the mental condition of the patient 
will reveal the cerebral mischief, which continues to progress even after 
any coexisting indigestion has been corrected. There is, moreover, 
sluggish intelligence, and partial paralysis or rigidity of certain mus- 
cles of the extremities. Attacks of delirium or mania finally confirm 
the diagnosis, and the patient usually dies in a state of coma. 

Intra-cranial disease of a chronic character is often so obscure as to 
leave even the most experienced in doubt, and the post-mortem exam- 
ination sometimes produces revelations that disconcert the medical 
attendant. Due regard to some of the characteristic phenomena in the 
accompanying table will often serve to clear up the doubts surround- 
ing a difficult case. 



94 



DIFFERENTIAL DIAGNOSIS. 



Bkain Tumor. 

Of slow develop- 
ment.. 



Intellect not dis- 
ordered at first. 



Headache violent, 
paroxysmal and of- 
ten localized. 

Paralysis slow in 
appearing, and of- 
ten limited to the 
muscles of eye or of 
the face ; more 
rarely hemiplegia. 

Convulsions a 
common symptom, 
epileptiform in char- 
acter. Not followed 
by palsy or hebe- 
tude. 

Vertigo and tinni- 
tus aurium. 



Vomiting. 



Softening 
(White). 

Approach and pro- 
gress slow. Follows 
embolism or apo- 
plexy. Non-inflam- 
matory. 

Early affection of 
intelligence. Mark- 
ed impairment of 
memory. 

Dull and constant. 



Motor and sensor 
phenomena more 
frequent and promi- 
nent. Partial pal- 
sies and disturb- 
ances of sensibility 
subsequently. 

Begins often with 
apoplectiform at- 
tacks, which seldom 
occur afterward. 



Vertigo. 

Not unfrequently. 



Abscess. 



Follows injury to 
the skull, or chronic 
disease of the head. 



Varies with seat. 



Sudden in its de- 
velopment and gen- 
eral. 

Course is much~) 
more rapid ; con- 
vulsions, drowsi- 
ness, paralysis and 
coma quickly de- 
veloped. 

Convuls ions 
early ; paralysis 
belongs to devel- 
oped stage. 



Rare. 



Chronic 
Meningitis. 

Caused by syph- 
ilis,rheumatism, dis- 
ease of bones, blows 
upon the head, etc. 

Intelligence not 
affected, except dur- 
ing attacks of delir- 
ium. 

Subject to exacer- 
bations, but gener- 
ally chronic. 



In consequence of 
meningeal exuda- 
tion may present the 
clinical signs of a 
brain tumor. 



More vertigo. 
Frequent vomit- 



Thrombosis of 
Sinuses of Brain. 

Sudden develop- 
ment of symptoms. 



May be uncon- 
sciousness or not. 
Intelligence subse- 
quently good. 

No headache ; 
oedema of forehead 
and eyelids. 

f May be coma; 

' varies greatly, ac- 
cording to part of 
brain whose vas- 
cular supply is 
disturbed. 



Very rare. 

Varies. 

No vomiting. 



SCLEROSIS. 
Sclerosis is a disease of the nerve centres, in which there is increase 
of connective tissue elements, without primary involvement of the nerve 
cells. It may exist as diffused cerebral sclerosis, spinal sclerosis (several 
forms), cerebro-spinal sclerosis (sclerose en plaque), and glosso-labio- 
laryngeal paralysis. Cerebral sclerosis occurring in children can be dis- 
tinguished from deficient development by the following characteristics : 



DEFECTIVE DEVELOP- 
MENT OF INTEL- 
LIGENCE. 

Intelligence stationary,' instead 
of progressing with age. 

Not connected with disease. 



Speech restricted to few words, 
imperfectly pronounced. 



DIFFUSED CEREBRAL 
SCLEROSIS. 



retrogressive and 
Often terminates 



Intelligence 
more affected, 
in idiocy. 

May follow injury to head, zy- 
motic fevers, severe application of 
body or mind. 

Never learns to talk, or speech 
becomes imperfect or lost after it 
has been acquired. 



DISEASES OF THE NERVOUS SYSTEM. 



95 



DEFECTIVE DEVELOP- 
MENT OF INTEL- 
LIGENCE. 

No paralyses. 

Muscular system in good condi- 
tion. 

No convulsions. 

Improved by training and edu- 
cation. 



DIFFUSED CEREBRAL 
SCLEROSIS. 

Usually more or less hemiplegia. 

Arrest of growth of certain parts 
of body, with contraction and dis- 
tortion of affected limbs. 

Frequent convulsions. 

Progress very chronic, and may 
live to advanced age. 



LOCALIZATION OF BRAIN DISEASE. 
The localization of diseases of the brain is a subject of great interest. 
In order that a correct diagnosis should be made, the important anat- 
omical and physiological data must ever be borne in mind. We pro- 
ceed first to the consideration of 



LESIONS OF THE CEREBRAL CORTEX. 

[The accompanying excellent diagram, or physiological map of the 
F * 




CORTICAL CENTRES OF THE HUMAN BRAIN. 

S, Fissure of Silvius ; c, Fissure of Rolando ; po, Parieto-occipital fissure. A, Ascending frontal gyrus ; B, 
Ascending parietal gyrus; F 3 , Third frontal gyrus; P 2 / Gyrus angularis. Circle I, Seat of lesions which 
(on the left side) cause aphasia. Circle II, Seat of lesions which convulse or paralyze the upper extremity 
of the opposite side. Dotted Circle III, Seat of lesions which probably convulse or paralyze the face on the 
opposite side. Dotted Oval IV, Seat of lesions which probably convulse or paralyze the lower extremity of 
the opposite side. These districts receive their blood supply chiefly from the middle cerebral artery. The 
remaining letters refer to anatomical points which explain themselves. 



9 6 



DIFFERENTIAL DIAGNOSIS. 



principal cerebral cortical centres, modified from Ferrier and Ecker, 
by Seguin, will be found very useful, as it embodies the results of the 
recent researches of Fritsch and Hitsig, Ferrier, Dalton and 
Seguin;* particularly as this subject is now attracting much attention.] 
The following is the summary given by Seguin {loc. cit.) : — 



PHYSIOLOGICAL. 

" In the first place, it appears al- 
most absolutely certain that in man 
a lesion involving the posterior : 
part of the third frontal convolu- I 
tion (on the left side usually) causes j 
aphasia; i.e., impairment or loss 
of articulate speech, or even of 
language in general. It would ! 
seem, besides, that (i) lesions of 
the same part on either side of the 
brain produce paresis of many 
muscles concerned in lingual and 
pharyngeal movements ; (2) that 
lesions of the anterior folds of the 
island of Reil (convolutions which 
are continuous with the third fron- 
tal), may also produce aphasia; 
and that (3) loss of speech may re- 
sult from injury to the white sub- 
stance lying between the third 
frontal gyrus and the basis cerebri. 
I believe in a not too limited local- 
ization of the motor functions ex- 
erted in language, and would 
graphically represent this by the i 
circle marked I. 

" In the second place, lesions | 
limited to the inferior portions of! 
the ascending frontal and parietal 
gyri have produced spasmodic and 
paralytic phenomena limited to the 
upper extremity of the opposite I 



PATHOLOGICAL. 

" I. The symptoms of an irrita- 
tive lesion of these parts consist in 
convulsions, with or without sub- 
sequent transient paralysis ; e. g., 
such a lesion in circle III would 
give rise to spasmodic movements 
in the superficial muscles of the 
face on the opposite side, with slight 
paralysis. Irritative lesions of the 
regions inclosed in circles II and 
IV will cause convulsions limited 
to, or first appearing in the hand 
and arm, or foot and leg, of the 
opposite sides. As regards circle 
I (Broca's speech centre), we know 
little of the effects of its patholog- 
ical irritation. In one case which 
I have placed on record, a thick- 
ening of the meninges involving 
the third frontal convolution of the 
left side produced intermittent and 
incomplete aphasia. 

" It was by the close study of the 
clinical and pathological aspects of 
cases of localized epilepsy (fingers 
and hands), that Dr. J. Hughlings 
Jackson was enabled to form his 
theory of motorial discharges from 
irritation of the cortex cerebri, and 
thus pave the way for Ferrier's 
admirable researches. Dr. Jackson 
must, I think, be considered, after 



* See Lectures in New York Medical Record, delivered at the College of Physicians and 
Surgeons, New York, in Jannary, 1878. 



DISEASES OF THE NERVOUS SYSTEM. 



97 



PHYSIOLOGICAL, 
side. I am disposed to admit as 
highly probable that these parts 
are connected in the healthy living 
man with the various voluntary 
movements of the arm and hand. 
This zone is represented by circle 
II. 

" I am not prepared to go further 
in admitting pathologically proved 
cortical centres, but would add that 
there are some reasons for believ- 
ing that future autopsies will locate 
one centre for the external facial 
muscles just forward of the two 
centres named above, viz., the 
region included in the dotted cir- 
cle III ; and another for move- 
ments of the legs upon the upper 
parts of the ascending frontal and 
parietal, as roughly indicated by 
dotted oval IV." 



PATHOLOGICAL. 
Prof. Broca, as the founder of our 
present growing doctrine of corti- 
cal localizations. 

" 2. Destructive lesions of por- 
tions of the excitable district pro- 
duce paralysis in peripheral parts 
across the median line. The symp- 
toms will, to a certain extent, cor- 
respond with the precise location of 
the lesions, very much as in irrita- 
tive lesions; e.g., embolism of the 
first branch of the middle cerebral 
artery on the left side will cause 
softening of the posterior part of 
the third frontal gyrus, with the 
symptom aphasia. A destructive 
lesion of the principal part of the 
motor zone on the right side will 
produce left hemiplegia without 
aphasia ; but if this lesion occupy 
the left hemisphere, loss of speech 
will co-exist with the paralysis." 



It must be added that secondary descending degeneration ensues 
after destructive lesions of the motor regions of the cortex, and that 
we have late contracture or rigidity of the paralyzed limbs as part of 
the symptom group. 

Negative characters of these cortical lesions are preservation of sen- 
sibility in the paralyzed parts, and (except with epileptic attacks) pres- 
ervation of consciousness, and incompleteness of paralysis. 

In diffused lesions of the cortex the chief symptoms are delirium, 
convulsions and pain; evidences of intense irritation. The coma and 
paralysis which follow may in some degree be caused by impaired 
nutrition of the cortex, but more probably by circulatory and tension 
changes in the whole encephalic mass. 

As regards sensory cortical centres, Dr. Seguin believes that we 
have as yet no pathological data for their study. 
7 



9 8 



DIFFERENTIAL DIAGNOSIS. 



DISEASE OF BRAIN CENTRES OTHER THAN CORTICAL 

The following tabular view of the paralyses, with the localization of 
the lesion, is mainly that of Professor DaCosta.* 



SYMPTOMS. 
Hemiplegia, without disturbance 
of sensation. Incomplete paralysis 
of face. Electro-muscular con- 
tractility and tendon-reflexes nor- 
mal or increased. Generally ac- 
companied by apoplectic symptoms. 
Right-sided palsy usually accom- 
panied by aphasia. 

Crossed paralysis (i. e. face of right 
; and hemiplegia of left, or vice versa). 

Paralysis of face marked, one-sided 
\ loss of motion and sensation. Gen- 
■ eral symptoms : giddiness, nausea. 

Albumen or sugar in urine. 

Same as above, except complete 
facial paralysis (both sides of face). 

Paralysis of arm and leg, slight 
paralysis of face, dilatation of pupil 
-of opposite side, with external 
squint (3d nerve paralysis). 

Paralysis of motion of arm or 

Teg incomplete and transitory, 

soon followed by rigidity, no loss 

of sensation. Reflexes superfical 

and deep, preserved or increased. 

Paralysis of one arm and same 
side of face, sensation unimpaired; 
if palsy right-sided, aphasia. 

Motion more or less completely 
affected on both sides of the body; 
sensibility diminished or lost on 
one side, increased on the other; 
the same as to temperature. 



SEAT OF LESION. 
In corpus striatum, less mark- 
edly optic thalamus; on side 
opposite to hemiplegia. 



Pons Varolii upon opposite side 
to palsy of limbs (below decussation 
of facial nerve). 



Pons at level of decussation of 
facial nerve. 

Crus cerebri on side correspond- 
ing to affected eye. 

Cortical part of brain in motor 
zone, on side opposite to palsy. 



Middle or lower third of the 
ascending convolutions in facial 
and manual centres, on side oppo- 
site to palsy. 

Medulla oblongata on. side of 
increased sensibility and tempera- 
ture, and at level of decussation of 
anterior pyramids. 



*" Medical Diagnosis," 6th Edition, Philadelphia, 1884, page 122. 



DISEASES OF THE NERVOUS SYSTEM. 



99 



The observations of Brown-Sequard have demonstrated that in ex- 
ceptional cases of brain tumor or lesion the symptoms do not corres- 
pond as accurately with the anatomical position of the lesion as is 
above indicated. At the present time these cases must be looked 
upon as really exceptional, and as not affecting the rules which have 
just been cited. More particularly are these aberrant symptoms likely 
to appear in tubercular disease of the brain. Indeed, Prof. Henoch 
(in Charite Annalen, fourth year), reports nine cases of tuberculosis of 
the brain that show how risky it is to localize, basing this upon recent 
physiological investigations. His results were as follows: — 



SYMPTOMS. 
Case I. — Left hemiplegia. 



Case II. — Tremor and paresis of 
the right side, finally, contraction 
of all extremities. 



Case III. — Hemiplegia and con- 
tracture of the left side, as well as 
of the facial nerve. 

Case IV. — Contracture and in- 
voluntary motion on right .half of 
face and body. 

Case V. — Complete absence of 
symptoms until meningitis set in. 

Case VI. — Paralysis of the left 
abducens, the left iris and right 
arm. 

Case VII. — Absent, until men- 
ingitis sets in. 

Case VIII. — Completely absent. 

Case IX. — Paralysis of the right 
abducens. 



LESION. 
Multiple tubercles of the cortical 
layer of both hemispheres, the 
frontal lobes and tubercle of the 
left half of the cerebellum. 

Tubercle of the left frontal lobe, 
the left corpus striatum, both tha- 
lami and right half of the cerebel- 
lum. 

Tuberculosis of the right frontal 
lobe. 



Tuberculosis of the left frontal 
lobe. 

Tuberculosis of the commissure 
of the cerebellum and of both hem- 
ispheres. 

Tuberculosis of the commissure 
of the cerebellum. 

Tubercle in the pons. 

Tubercle of the left posterior lobe. 

Tuberculosis of both posterior 
lobes, the posterior corpora quad- 
rigemina, the pons and left crus 
cerebelli. 



IOO DIFFERENTIAL DIAGNOSIS. 

Of all these cases only II and III show the possibility- that lesions 
of the motor centres of the frontal convolutions produce motor lesions 
of the opposite side. This chance of diagnosis, however, is very lim- 
ited, as is shown by the other cases where these locations were free 
from disease, and yet the :"ame symptoms produced with lesions in 
other parts of the brain, even cerebellum I Case VI). Sometimes the 
intensity of the symptoms does not seem to correspond with the in- 
tensity of the lesion (V and VI). Henoch believes that a close study 
of the fibres leading from and to these physiological centres will do 
much to reconcile the apparent contradictions between pathological 
and symptomatological differences.* 

The subject of insanity will be separately considered at the end of 
this section.) 

INFANTILE CEREBRAL PARALYSIS. 

Dr. R. Xorris Wolfenden, in the Practitioner for September, 1886, 
describes four cases of this affection. The disease has also been called 
spastic cerebral hemiplegia, and, again, pohencephatitis acuta. These 
names, among them, manage to describe something of the disease. 
The last, as indicating the pathology, and being analogous to poliomy- 
elitis, is on some accounts the best, were it not too technical and 
pedantic. One of these cases was briefly as follows : A boy of ten 
months was attacked with a series of convulsions, followed by paraly- 
sis of the left arm and leg. For six months the leg and arm were 
spastic; then they relaxed, leaving permanent weakness. Epileptiform 
attacks continue at intervals of about twice a week. Intelligence had 
been much impaired, so that at eight years he could not be taught to 
read. Weakness of the arm and leg continued, and the fingers were 
subject to slight athetotic movements. The tendon-reflexes of this 
side were exaggerated. There were no reactions of degeneration. 

The disease is distinguished from spinal paralysis by the affections 
of the intellect, speech, special senses (sometimes), and the absence of 
impaired sensibility. In the spinal form also there is atrophy and 
coldness, with progressive reactions of degeneration, while the spastic 
condition is not an early and characteristic sign. Club-foot deform- 

* Cincinnati Lancet and Clinic, May 31, 1S7S. 



DISEASES OF THE NERVOUS SYSTEM. 



IOI 



ities are more constant and persistent in tke latter. The cerebral form 
may be said to occur more as a hemiplegic and epileptic type. The dis- 
ease has followed dentition and the eruptive fevers, but in many cases 
the causes cannot be determined. It is an affection of early infancy.* 

SPINAL DISEASES. 

A leading symptom of many diseases of the spinal cord, whether 
functional or organic, is paraplegia. This is so rarely of cerebral 
origin that ordinarily the brain may be omitted from the discussion, 
unless there is the coexistence of distinct evidences of brain disease, 
as headache, impaired cerebration, affections of special senses, and par- 
alysis of parts supplied by nerves arising above the spinal cord. 

The following classification of diseases giving rise to paraplegia, with 
their characters, has been proposed by Prof. H. C. WooD.f 



ORGANIC. 



Disease of the cord. 



FUNCTIONAL. 

Anaemic. 



Reflex (from peripheral 
irritation, renal, preputial, 

etc.) 



Dyscrasic 
etc.). 



(diphtheritic, 



HYSTERICAL. 

Hysteria. 



The last-mentioned, hysterical, is also functional, but simulates the 
organic more closely than does the second group. (For further con- 
sideration of Hysterical Paralysis, see Hysteria.) It must be admitted, 
however, that so-called functional disorder cannot long exist without 
being followed by change in structure. 

The general distinctions between the organic and functional para- 
plegias may be presented as follows : 



ORGANIC. 
Onset may be almost instantan- 
eous or very rapid, though some- 
times gradual. 

Usually at some period spasm or 
pain in the affected limbs. 



FUNCTIONAL. 
The onset always more or less 
gradual, except in the hysterical 
form, where the paralysis may be 
abrupt. 

Spasms or pain rarely or never 
present. 



* J. H. Lloyd, Phila. Med. Times, January 22, 1887. 

f " On the Diagnosis of Diseases Accompanied by Paraplegia.' 



1875- 



102 



DIFFERENTIAL DIAGNOSIS. 



ORGANIC. 

Often a sensation of a band or 
stricture around the waist, girdle- 
paiti (pathognomonic). 

Anaesthesia frequent and often 
complete. 

Retardation of sensation (a per- 
ceptible time elapses between the 
patient's seeing his feet touched 
and feeling that they are) (pathog- 
nomonic). 

Symptoms of paralysis of the 
bladder. 



FUNCTIONAL. 



Not found. 



Anaesthesia not observed, or but 
slight. 

Sensation, if present at all, is not 
retarded. 



No symptoms whatever of vesi- 
cal paralysis, except in the hyster- 
ical form. 



Where the bony canal is involved and caries is present, this condi- 
tion may generally be discovered by Rosenthal's test. This consists 
in passing down the back a pair of electrodes attached to a faradic bat- 
tery of some power, one pole being placed upon each side of the spine. 
Under these circumstances if there be any caries or inflammation of 
the vertebrae, the moment its locality is reached, the patient starts or 
screams, from the burning, sticking pain caused by the passage of the 
galvanic current through the inflamed tissue. Dr. Wood states that 
he has not found this test as trustworthy as its originator claimed it to 
be, and as, apparently, it ought to be. In cases simulating caries, how- 
ever, the pain is probably not so severe as where the vertebrae are 
really affected. Moreover, absence of the pain in any case seems to 
be conclusive evidence of the non-existence of bone disease. 

The following study of the principal organic spinal diseases, from 
the writings of Seguin, Charcot, and other authorities, when taken in 
conjunction with the tabular view of paralysis, will often enable the 
diagnostician to determine both the nature and location of a spinal 
lesion: 

DISEASES OF SPINAL CORD. 

Transverse diffused myelitis (acute and chronic) { PC ^^ ^^&£^ ° f * ***** P ° rti ° n * ^ ^ 

( Patches of disease situated primarily in the connective tissue, 
Disseminated sclerosis {sclerose en plaques) I and scattered without regard to the "systematic" grouping 

I of the nervous elements. 



DISEASES OF THE NERVOUS SYSTEM. 



03 



Degenerative disorders, 
mainly affecting the 
columns of the cord. 



Myelitis of the gray 
matter of the anter- 
. ior cornua. 



Antero-lateral sclerosis 
(amyotrophic). 



Sclerosis of the posterior columns 
(Locomotor ataxia). 
Duchenne's Disease. 



Symmetrical lateral sclerosis. 
(Paralysis spinalis spastica.) 



Poliomyelitis anterior. 



Acute 



Its distribution is "sys- 
tematic," and probably , 
it is essentially a prim- 
ary disease of the neive 
elements rather than of 
the connective tissue. 
Ditto, though its pathology is as yet almost 
purely a matter of inference. Its characteristic 
symptom is muscular rigidity. 
( Infantile paralysis. 
( Acute spinal paralysis of the adult. 



Subacute. 
Chronic. 



Progressive muscular atrophy and 
progressive bulbar paralysis (" labio- 
glosso-pharyngeal paralysis"). 



Often classified as a special form of po- 
liomyelitis chronica, but characterized 
by the absence of paralysis, except 
such as is directly due to the muscular 
atrophy. 



Not yet thoroughly studied, but believed by Charcot and others to involve at 
once the lateral columns and the anterior cornua ; the characteristic symptoms 
being atrophy with contracture, beginning in the upper extremities. 



TABULAR VIEW OF SPINAL PARALYSIS. 



SYMPTOMS. 

Paralysis of compressor ure- 
thral, accelerator urinse and sphinc- 
ter ani. No paralysis of muscles 
of the legs. 

Paralysis of muscles of bladder, 
rectum and anus. Loss of sensa- 
tion and motion in muscles of legs, 
except those supplied by anterior 
crural and obturator nerve. 

Both legs paralyzed as to sensa- 
tion and motion. Loss of power 
over bladder and rectum. Lateral 
muscular walls of abdomen para- 
lyzed, thus interfering with expira- 
tory movements of respiration. 
Electro-muscular contractility dim- 
inished or. lo'st. 

Paralysis of legs, etc., as above. 
Paralysis of all the intercostal mus- 
cles, and consequent interference 
with inspiration. Paralysis of 
muscles of upper extremities, ex- 
cept those of the shoulders, which 
receive their nerves from the higher 
portions of the cervical region. 



SEAT OF LESION. 



In the termination of the cord, 
low down in the sacral canal. 



In the cord, at the upper limit 
of the sacral region. 



In the cord, at the upper limit 
of the lumbar region. 



In the cord, low down in the 
cervical region. 



104 



DIFFERENTIAL DIAGNOSIS, 



TABULAR VIEW OF SPINAL PARALYSIS. 



SYMPTOMS. 

In addition to the preceding, 
difficulty of swallowing and vocal- 
ization, contraction of pupils, pal- 
pitation of heart and priapism. 

In addition to above, paralysis 
of the phrenic nerve and dia- 



SEAT OF LESION. 

In the cord below the middle 
cervical region. . 



In the cord, at or above the 
middle of the cervical region, or 
phragm, of the scaleni, intercos- the level of the fourth cervical pair 
tales, serrati magni, and many of of spinal nerves, 
the accessory respiratory muscles 
which act upon and from the 
shoulder. Death resulting at once 
from suspension of all respiratory 
movements. 



Paraplegia developing itself sym- 
metrically. 

Paraplegia of the legs. 

Paraplegia of the arms. 

Cerebral paraplegias, so-called, 
are very rare, and are in reality 
two distinct hemiplegias. 

Paraplegia from disease of the 
vertebral column. 



Characteristic symptoms of tabes 
dorsalis or locomotor ataxia. 

Progressive muscular atrophy. 



Hemiplegia with crossed hemi- 
anesthesia. 



Anterior half of the medulla 
spinalis or its sheaths. 

Dorso-lumbar enlargement of 
cord. 

Cervical enlargement of cord. 

In both sides of the brain. Ex- 
ceptions in cases of disease of the 
medulla oblongata (very rare]. 

Roots of spinal nerves at point 
of injur}*, especially posterior roots, 
which long remain in a state of 
painful excitation. 

Posterior part of med. spinalis. 

Gray substance of spinal cord 
vicinity of the central canal or dif- 
fused through anterior roots. 

In one lateral half of spinal cord. 
The hyperesthesia of the para- 
lyzed side is probably due to 
paralysis of the vaso-motor nerves 
of that side. 



DISEASES OF THE NERVOUS SYSTEM. 105 

TABULAR VIEW OF SPINAL PARALYSIS. 



SYMPTOMS. 

Bilateral neuralgia of the legs 
and arms accompanying symptoms 
of tabes dorsalis. 

Bilateral contractions affecting 
the extensor muscles. 

Unilateral contractions affecting 
the flexor muscles. 



SEAT OF LESION. 

In posterior roots of spinal 
nerves and their prolongation into 
the gray substance of the cord. 

In the spinal cord. 
In the brain. 



Diseases of the spinal marrow have been classified by Dr. Wood 
according to the rapidity of their onset, as follows, the attack being 
considered rapid when decided paralysis has developed within forty- 
eight hours ; 



RAPID ONSET. 



Congestion. 
Meningeal apoplexy. 
Spinal apoplexy. 
Acute myelitis. 



SLOW ONSET. 



Sexual exhaustion. 
White softening. 
Chronic myelitis. 
Tumors. 



In congestion of the cord the diagnosis rests upon : Suddenness of 
onset; uniform, bilateral loss of voluntary motion, reflex activity and 
sensation ; absence of all symptoms of irritation, such as spasms or 
violent pains ; absence of constitutional disturbance. It must also be 
remembered that the palsy affects first and most severely the lower 
limbs, but may rise to the arms, and, finally, to the muscles of respira- 
tion, and thus prove fatal ; that so far as the paralysis extends, all the 
muscles are involved ; that motion is affected more than sensation ; 
and that very rarely, if ever, does ulceration or other indication of 
trophic changes occur. 

In meningeal spinal apoplexy the symptoms are also due to pressure, 
but the effused blood not only disturbs the cord by pressing upon it, 
but also irritates the membranes and the nerve-roots, especially when 
first thrown out. Consequently, in the first few hours or days of a 
meningeal hemorrhage, there are violent spasms and pains, due either 
to an incipient meningitis, or more probably to a direct irritation of 



io6 



DIFFERENTIAL DIAGNOSIS. 



the nerve-roots. The extent and amount of the symptoms vary, of 
course, with the position and amount of the hemorrhage. Later there 
are symptoms oi pressure, varying in intensity with the amount of the 
effusion ; and absence of febrile symptoms, unless decided meningitis 
be produced by the clot. 

In true spinal apoplexy the symptoms come on with absolute abrupt- 
ness. The cord is so small a body that a clot in its substance inter- 
rupts at once its function. The paralyses of motion and sensation are 
complete, and reflex movements are greatly exaggerated. As there is 
no correlation of the spinal nerve-roots, the spasms and pains of men- 
ingeal hemorrhage are wanting. 

Acute primary myelitis is a very rare affection. The diagnosis 
should present no difficulty. The distinct febrile reaction, which is 
stated to be always present, separates it at once from all other acute 
affections of the cord proper, so that it can be confounded only with 
acute meningitis. Probably, in the majority of cases, it exists coinci- 
dent^ with this disorder ; but even when it is isolated, the symptoms 
at first closely simulate those of meningitis. 

COMPARISON OF ACUTE SPINAL DISEASES. 



Constant pain in the spine 
at a point corresponding with 
the upper limit of inflamma- 
tion, rendered more acute by 
pressure on vertebral spine. 

The alternate application of 
ice and hot sponge to spine 
causes the same burning sen- 
sation at seat of lesion, but 
above it the sensation is nor- 
mal. 

Sensation as of a cord or 
ligature around the body at 
the limit of paralysis always 
present when dorsal region is 
affected ; when higher up 
spasm of the sphincters and 
priapism often occur. 



MENINGITIS. 

Pain usually rheumatic in 
character, diffused along the 
spine, not increased by pres- 
sure ; but augmented by flex- 
ions of trunk. 

Nerves coming out through 
the inflamed part of the men- 
inges, the seat of acute pain, 
much increased by move- 
ments of limb. 



Frequent spasms of muscles 
of the back. Spasm of sphinc- 
ter vesicae may occur, followed 
by retention of urine and par- 
alysis. 

Convulsive movements of 
paralyzed parts. 



CONGESTION. 

Formication alternating 
with numbness in the begin- 
ning of the attack, especially 
in fingers and toes. 

Only slight pain in spine, 
scarcely increased by pres- 
sure. 



Frequently hyperaesthesia ; 
sphincters more paralyzed 
than in other forms of paral- 
ysis (Brown-Sequard). 



DISEASES OF THE NERVOUS SYSTEM. 



IO7 



COMPARISON OF ACUTE SPINAL DISEASES. 



MYELI1IS. 

Paraplegia complete. 



Anaesthesia or paresthesia 
(except when gray matter is 
not involved, which is rare), 
muscular sensibility much 
impaired, early. 

When disease is high up 
in dorsal region, energetic 
reflex movements may be 
produced. 

Marked tendency to bed 
sores ; sloughs form early on 
sacrum and nates. 



MENINGITIS. 

Paraplegia varies in de 
gree, sometimes increasing 
and subsequently rapidly di- 
minishing. 



Anaesthesia very rare 
erally hyperesthesia. 



gen- 



Increased reflex move- 
ments, which cause pain, 
may be excited. 

Less marked in uncompli- 
cated cases of meningitis. 



CONGESTION. 

Paralysis generally not 
limited to lower limbs, but 
involves upper extremities 
and respiratory muscles. In 
some cases power of mov- 
ing paralyzed legs is better 
after resting ; ordinarily, how- 
ever, the paralysis is worse 
on first rising in the morn- 
ing. 

Frequently morbid increase 
of sensibility. 



Slight spasmodic move- 
ments sometimes observed in 
paralyzed parts. 

Ulceration occasionally 
happens. 



CHRONIC SPINAL DISORDERS. 

In the slow or chronic forms of spinal disease, spinal tumors may be 
considered first. There are three classes of phenomena to be looked 
for in this disease: local symptoms of diseased structures; atrocious 
pains at a distance from the seat of the disease, due to the involvement 
of nerve-roots and nerves, where they pass through the inflamed tissues; 
and paralytic symptoms, the results of pressure, and to some extent 
of a local myelitis. In cases of suspected tumors of the spine all these 
symptoms are to be sought after. In cancer they are often all present, 
and the distant pains are especially remarkable for their atrocity. 

The other chronic spinal diseases may be classified with reference to 
the characteristic of tremors as follows : 



WITHOUT TREMORS. 

Sexual exhaustion. 
White softening. 

Chronic myelitis \ , .. *»" 

J \ sclerotic. 

Local myelitis. 



WITH TREMORS. 

Paralysis agitans. 
Multiple sclerosis. 



The difference between sexual exhaustion and myelitis is probably one 
of degree only; but the former is curable, the latter is not. 



io8 



DIFFERENTIAL DIAGNOSIS. 



CHRONIC DEGENERATIVE DISEASES OF THE CORD. 

In distinguishing the various forms of disseminated or multilocular 
cerebro spinal affections, the following table, given by Professor Char- 
cot, will render valuable assistance. The symptoms of greatest im- 
portance are in italics. 

CEREBRO-SPINAL AFFECTIONS. 





LOCOMOTOR 


MULTILOCULAR 


DISSEMINATED 


GENERAL 




ATAXIA. 


SCLEROSIS. 


SYPHILOSIS. 


PARALYSIS. 




Epileptiform Apo- 


Epileptiform Apo- 


Epileptiform Attacks. 


Epileptiform Apo- 




plectic Attacks. 


plectic Attacks. 


Paraplegic Hemi- 
plegic Epilepsy. 


plectic Attacks. 




Vertigo. 


Vertigo. 


Vertigo. 


Vertigo. 




Diplopia, Strabis- 


Diplopia. 


Diplopia. 


Diplopia. 


O 


mus. 










Nystagmus. 








Amaurosis. 


Amblyopia, White 


Amblyopia, Optic 


Amblyopia. 


3 

> 




Atrophy. 


Neuritis. 




» ■ 


In equality of Pupils . 






Inequality of Pupils. 


U 


Facial Anesthesia . 




Headache, Fi x e d 


Headache. 


' < 






Pain. 






Deafness. 










Meniere' 's Vertigo. 










Embarrassment of 


Embarrassment of 




Embarrassment of 




Speech. 


Speech. 




Speech. 




Laryngismus. 


Difficult Deglutition. 








. 


Pneumogastric Palsy. 


Total Facial Palsy. 




■J E2 


Gastric Crises. 


Gastric Crises. 


Non-nervous Crises. 




OS O 


A T ephritic Crises. 








« £ - 


Vesical Crises. 








s s 


Paresis of Bladder. 






Paresis of Bladder. 


"^ en 


Cystitis. 









en* 
3 
O 
h 

S 

g ■ 

< 

■Si 


Girdle-pain. 
Hyperesthesia, An 

assthesia. 
Inc o or din ated 

Movement. 
Contractures and 

Trepidations. 


Lightning pains. 
Plaques. 

Incoordination. 

Special Trembling. 

Spasmodic Paraple- 
gia. 


Pseudoneural Pains. 
Spinal Hemianes- 
thesia. 

Spasmodic Paraple- 
gia under form of 
Hem iparaplegia . 


Lightning Pains. 
Tingling. 

Incoordination. 

Special Trembling 
of Hand. 

Paresis. Trepida- 
tion. 


s si 

O e- 
H >< 


Eschars. 
Arthropathies. 
Fractures. 
Muscular Atrophy. 


Eschars. 
Arthropathies. 

Muscular Atrophy. 




Eschars. 
Muscular Atrophy. 



DISEASES OF THE NERVOUS SYSTEM. IO9 

In applying these symptoms in practice, we should, of course, give 
first attention to those which are most characteristic. Thus, if we ob- 
serve, in a patient, ataxy with nystagmus, we think at once of multi- 
locular sclerosis and not of locomotor ataxy (tabetic series), because 
nystagmus is a valuable symptom of multilocular sclerosis. In the 
same way spasmodic paraplegia (recognized by the continual trem- 
bling movements which are produced when a single blow is struck 
upon the muscle) we find is produced by a localized lesion in the cord, 
more particularly involving the lateral columns. 

In order that these forms shall be better understood, it may not be 
out of place to review some of the chief clinical manifestations of scle- 
rosis of the cord. 

In sclerosis of the antero-lateral white columns, Dr. Gowers* states 
that there is loss of voluntary power below the lesion, descending de- 
generation in the anterior and lateral columns (direct and crossed 
pyramidal tracts, especially the latter), and over-action of the lower 
centres. This over-action may be manifested only as excessive knee- 
reflexf and developed ankle-clonus (tendon-reflex), or it may increase 
from this to spasm and rigidity — spastic paraplegia. There is no 
wasting unless the degeneration extends from the lateral columns to 
the anterior cornua. Then we have a combination of spasm and wast- 
ing, in which, if the cornual degeneration proceeds, the spasm and 
rigidity may lessen as the degeneration advances. In disease limited 
to the lateral columns (at any rate, when the disease is limited to the 
pyramidal tracts) there is no loss of sensation or incoordination, and no 
interference with the nutrition of the skin. These symptoms of " spas- 
tic paraplegia" may arise from a primary degeneration in the lateral 
columns, limited thereto {lateral sclerosis). Such cases are extremely 
rare, and in the majority the disease is a focal lesion more or less ex- 
tensive at some level in the dorsal or cervical cord, and the degenera- 
tion in the lateral columns is secondary. The evidence of the latter 
form is afforded by the frequently sudden or rapid onset of the symp- 
toms in the first instance (primary sclerosis being always gradual in 
onset), and the evidence which may generally be discovered that there 

* Address delivered before the Medical Society of Wolverhampton, Oct. 7th, 1879. 
f See page 102, note on Patellar-Tendon Reflex. 



110 DIFFERENTIAL DIAGNOSIS. 

• 

has been at some time, or is in some region, a lesion, which extends 
beyond the lateral columns. Descending lateral sclerosis, with sec- 
ondary spasmodic phenomena in the limbs, may even result from dam- 
age to the motor tracts above their decussation — in the medulla, the 
pons, or the motor parrs of the cerebral hemispheres. It occasionally 
results from bilateral injury to the surface of the brain during difficult 
birth, but such cases are very rare. 

2. In disease of the posterior columns there is interference with coor- 
dination without loss of power; eccentric pains, impaired sensation 
and diminution of reflex action, in consequence of the implication of 
the sensory roots. All these symptoms depend on disease of the root- 
zone of the posterior columns. Disease of the posterior median col- 
umn gives rise to no known symptoms. 

The posterior columns m.ay be damaged by any pathological pro- 
cess, and they are frequent seats of primary degeneration. The 
symptoms of locomotor ataxy usually present the following order 
L:ss of the deep reflexes, pains, incoordination, diminution of sensa- 
tion, loss of the superficial reflexes, occasionally interference with the 
nutrition of bones and joints. 

There is no loss of motor power or wasting as long as the disease 
remains limited to the posterior columns. It may, however, extend 
forward into the anterior cornua, causing muscular atrophy and weak- 
ness to be conjoined with the ataxy. Or the lateral columns may be 
affected at the same time as the posterior; we then have weakness as 
well as ataxy, but no wasting. The disease of the lateral columns 
causes increase of the deep reflexes, and this increase may thus coexist 
with incoordination, the increased action of the reflex centres being so 
great that they are not arrested by the damage to the posterior root 
(which is often, in these cases, slight . Thus we have the anomaly of 
ataxy with excess of the tendon reflex instead of its less. 

An important fact to remember regarding the posterior columns is 
their proneness to degenerate; they recover less readily than any other 
part of the cord. A lesion in one spot may set up a degeneration 
which ultimately involves them in their whole extent. Damage affect- 
ing the whole thickness of the cord may pass away from the rest and 
persist in the posterior columns, and even spread there. In such a 



DISEASES OF THE NERVOUS SYSTEM. I I I 

case we have ataxy succeeding loss of power. Strength returns, in- 
coordination remains. 

3. The anterior cornua contain the motor nerve-cells, which (1) in- 
fluence the nutrition of the motor nerve fibres proceeding from them, 
and consequently that of the muscles ; (2) constitute the terminal link 
in the path of the voluntary impulse from the brain to the muscles ; 
(3) form part of the reflex loop, probably also of the reflex centre, to 
which these muscles are connected. 

Hence we have as" the result of disease of the anterior cornua, (1) 
degeneration of the motor nerves and wasting of the muscles ; (2) loss 
of voluntary power, i. e. y paralysis of those muscles ; (3) interference 
with or arrest of the reflex actions in which these muscles take part. 

The extent ot these symptoms, whether they are unilateral or bilat- 
eral, affect many muscles or few, will depend strictly on the extent of 
the disease in the spinal cord. 

Of the three symptoms, the muscular wasting is incomparably the 
most important. Paralysis may result from disease elsewhere in the 
motor tract, i. e. t disease of the lateral column higher up. Loss of 
reflex action may depend on disease elsewhere in the reflex loop, i. e. y 
disease of the sensory fibres in or outside the cord. But muscular 
wasting is due only to a lesion of the motor cells, or to a lesion of the 
nerves, cutting the muscles off from the influence of these cells. In 
most cases we are able to exclude the latter without difficulty ; the 
state of muscular nutrition comes thus to be of the highest import- 
ance as indicative of the state of the anterior cornua of the cord. 

Disease of the anterior cornua is often combined with disease of the 
lateral (pyramidal) columns similar to the descending degeneration. 
Charcot believes that in these cases of degeneration in the lateral 
column is primary, its symptom, muscular rigidity, preceding the 
symptom of the cornual disease, muscular wasting, and he terms the 
affection " lateral amyotrophic sclerosis." Gowers believes, however, 
that this position needs reconsideration, and that the degeneration in 
the lateral columns is, sometimes at least, secondary to, or simultan- 
eous with, the disease in the cornua.* It often spreads, however, be- 
yond the fibres related to the degenerated cornua, and so may cause 
weakness and spasm in the limbs below the seat of the muscular atro- 



I I 2 DIFFERENTIAL DIAGNOSIS. 

phy. Thus we have wasting in the arms, and weakness with spasm in 
the legs, and even, as I have seen, wasting in the shoulder-muscles, 
and weakness without wasting in the hands. 

Certain lesions may damage the motor tracts slightly and impair 
conduction in a peculiar way, rendering it apparently unequal in dif- 
ferent fibres. As a consequence, the muscular action is unequal in 
different muscles, and intead of a balanced coordinated movement, we 
have an unbalanced jerky movement. This is seen especially when 
irregular islets of sclerosis affect the cord — disseminated or insular 
sclerosis — and, according to the researches of Charcot, it appears 
that this irregular conduction is the result of the unequal wasting of 
the medullary sheaths, the axis-cylinders remaining. A precisely sim- 
ilar symptom may result from pressure on the motor tract — as by a 
growth. Xot rarely this "disseminated" or "insular" sclerosis in 
one region is combined with a system-degeneration in another. An 
occasional combination, for instance, is the jerking movement (from 
cervical insular sclerosis) in the arms, and weakness with spasm (from 
lumbar lateral sclerosis) in the legs. 

4. A total transverse lesion of the cord at any level, however lim- 
ited in vertical extent, separates all parts below the lesion from the 
brain, and hence, so far as will and perception are concerned, produces 
the same effect as if the whole. of the cord below the lesion were de- 
stroyed. A section across the cord in the middle of the cervical en- 
largement, for instance, paralyzes all parts below the neck. Hence 
the extent of the paralysis indicates only the upward extent of the 
lesion. This is also indicated by the position of the girdle pain, or 
zone of hyperaesthesia, which is due to the irritation of the sensory 
roots in the lowest part of the upper segment — an important indication 
when the lesion is in the dorsal region, where the precise limitation of 
motor weakness may be recognized with difficulty. 

The Tendon Reflex. — For the diagnosis of posterior sclerosis, YVest- 
phal has noted the following symptom : " If a healthy man sits with 
one knee-joint resting upon the other (a very common attitude), and 
the ligamentum patellae of the supported leg be smartly struck just 
below the knee-cap with the side of the hand, a sudden contraction 
takes place in the quadriceps femoris muscle (of which the ligamentum 



DISEASES OF THE NERVOUS SYSTEM. 113 

patellae represents the tendon), and the foot is consequently jerked up- 
ward to a degree which varies in different individuals. Now, in con- 
firmed examples of locomotor ataxia this reaction does not take place. 
No matter on what part of the ligament below the knee-cap, or with 
what force the blow is struck, the foot hangs motionless. In order to 
establish with accuracy the absence of the phenomenon, certain pre- 
cautions ought to be taken. The leg should be bare ; the patient must 
not offer voluntary resistance to the movement of his leg, and the lig- 
ament should be struck with some hard implement which can be 
swung like a hammer. An ordinary wooden stethoscope answers very 
well if it is held loosely by the small end, and the blow given with the 
edge of the ear-piece. But, however administered, several blows 
should be struck on the ligament, slightly changing the position each 
time, as there is generally one spot from which the reaction is pecu- 
liarly energetic. This is usually a little below but very near to the 
patella. Ankle-clonus may be similarly developed by tapping the 
tendo-Achillis. 

The following are the conclusions given by Erb* in regard to the 
interpretation of symptoms : 

In diseases of the spinal cord, paralysis rapidly followed by a 
marked degree of atrophy and by the reaction characteristic of degen- 
eration, points to disease of the anterior roots (rarely), or of the gray 
anterior cornua (more frequently). In this case all reflex actions are 
absent. 

Paralysis with tension and contraction of muscles, without atrophy, 
is very probably due to some affection of the lateral columns. 

Paralysis without loss of reflex function and without atrophy, points 
to an affection of the parts which ascend to the brain, outside of the 
gray substance, or, at least, outside of the ganglia of the anterior cor- 
nua. Such are mostly cases of circumscribed disturbances of conduc- 
tion, the end of the cord below the lesion remaining intact. 

Paralysis, with trophic disturbances, gives room for suspecting an 
affection of the gray substance, since primary affections of the roots 
are rare. 

Very extensive palsy, with much atrophy, the reaction of degenera- 

* From a review in Journal of Nervous and Mental Diseases, Chicago, Oct., 1878. 
8 



- f l4 



DIFFERENTIAL DIA 



tion, absence of reflex acts, points to a widely diffused lesion of the 
anterior gray substance. 

Paralysis in the districts supplied by certain pairs of roots (both 
arms alone, or both crural nerves) points to a strictly localized affec- 
tion of roots, or lesion of the gray anterior cornua. The conclusions 
card to the nature of the lesion in the cord are far less certain 
than those relating to its place. 

Cases of spinal paralysis, accompanied by atrophy of the muscles, 
whether in children or adults, acute or chronic, are described under 
the heads of poliomyelitis anterior, acute, a?id chronic. 

Destruction of the central trophic apparatus, or its separation from 
the peripheral parts, produces the symptoms of degenerative atrophy. 
"Upon the whole, we are justified in assuming a disease of the anter- 
ior cornua when the electrical examination shows the existence of the 
reaction of degeneration, and consequently of degenerative atrophy : :" 
nerves and muscles, provided tlu disease is clearly of spinal origin" 
(Erb). 

In infantile palsy (lesion in the anterior cornua). observers ;.re not 
agreed as to whether the change in the ganglion cell is primary :r 
whether it is the consequence of an interstitial myelitis. . 

The following table will be found valuable in diagnosticating certain 
chronic disorders. 



CEREBROSPINAL 
SCLEROSIS 

Disease of adult life. 

Tingling and numbness; 
diminished muscular power, 
chiefiy in the legs. 

Eve symptoms absent in 
spinal form; when they oc- 
cur in cerebro- spinal form 
they are persistent and pro- 
gressive. 

Tremor or trembling fol- 
lows the par: 

One or both limbs paretic, 
ultimately becoming com- 
pletely power. ;- 



PARALY5IS AGITAX5. LOCOMOTOR ATAXIA 



In :_i persons :r.:er~; 
Ft.: ~iir.lv m ~.zt irrr.s 



X: :::_:;: eve ?y~r::rr.s 



Freceies r.iri.vs:s. 



Ir. iii.:s 

Tingling and numbness 
1 of legs without loss of pow- 
er (want of coordination ex- 
jistsj. 

Ocular troubles, defective 
vision and accommodation, 
j strabismus, ptosis or double 
vision. These symptoms tem- 
porary. 

Absent 



Muscular weakness in or.e No paralysis during the 
or both arms, and then ex- early stages, 
tends into lower extremities. 
Only rarely passing into true 

raralvsrs. 



DISEASES OF THE NERVOUS SYSTEM. 



CEREBROSPINAL 
SCLEROSIS. 

In the paretic stage the 
gait is distinctive; the foot is 
swung around, describing an 
arc of a circle, and brought 
flatly upon the ground. With 
this eccentric curvilinear pro- 
jection of the foot there is an 
exaggerated alternate semi 
rotation of both halves of the 
pelvis. 

No spontaneous tremor; al- 
ways caused by motion or ex- 
citement. 

Nystagmus, usually binocu- 
lar. 

Articulation slow and scan- 
ning. 

Intellect early impaired. 

Boring, gnawing, and lan- 
cinating pains rarely com- 
plained of. 

Early paresis, passing into 
paralysis, is characteristic. 



PARALYSIS AGITANS. 

In attempting to walk, first 
balances on his feet, and starts 
with head and trunk bent for- 
ward on the toes or fore part 
of feet, and with short steps 
goes hopping and trotting 
along at almost running speed 
(festination). 



Trembling early, incessant, 
even when at rest ; scarcely 
interrupted by sleep. 

Never met with. 



Articulation indistinct ; em- 
barrassed. 

Unaffected until late. 



LOCOMOTOR ATAXIA. 



A stumbling, staggering 
gait, without true paralysis. 



No tremor. 

Not present. 
Not affected. 

Not marked. 

Such pains frequently pre- 
cede the loss of motion. 



Paraplegia always a late 
phenomenon. 



(For diagnosis of Locomotor Ataxia from General Paralysis of the 
Insane, see page 123, under this head.) 

Paralysis may also be caused by reflex irritation, and closely simu- 
late organic disease of the cord. Brown-Sequard * gives the follow- 
ing points of distinction (with unimportant additions) : 



PARAPLEGIA. 



FROM REFLEX IRRITATION. 

1. Is preceded by an affection of 
uterus, bladder, kidneys, or pros- 
tate gland. May be caused by 
phimosis. 

2. Usually lower limbs alone 
paralyzed. 

3. No gradual extension of the 
paralysis upward. 



FROM MYELITIS. 



1. Usually no disease of the 
genito-urinary organs except as 
consequent on the paralysis. 

2. Usually other parts paralyzed 
besides the lower limbs. 

3. Most frequently a gradual ex- 
tension of the paralysis upward. 



Lectures on the Diagnosis and Treatment of Paraplegia," p. 33. 



n6 



DIFFERENTIAL DIAGNOSIS. 



PARAPLEGIA {Continued] 



FROM REFLEX IRRITATION. 

4. The paralysis is usually in- 
complete, an extreme debility or 
weakness of the limbs rather than 
paralysis. 

5. Some muscles more para- 
lyzed than others. 

6. Reflex power neither much 
increased nor completely lost. 

7. Bladder and rectum rarely 
paralyzed, or at least only "slightly 
so ; sphincter ani weak. 

8. Spasms in paralyzed muscles 
extremely rare. 

9. Very rarely pains in the 
spine, either spontaneously or on 
application of pressure, percussion, 
or a hot, moist sponge, or ice. 

10. No feeling of pain or con- 
striction around the abdomen or 
chest. 

11. No formication, pricking, or 
disagreeable sensations of cold or 
heat. 

12. Anaesthesia rare, the tactile 
sensibility being but slightly, if at 
all, impaired; but the muscular 
sense is almost lost. 

13. Usually obstinate gastric de- 
rangement. 

14. Variations in the degree of 
the paralysis corresponding with 
changes in the primary disease. 



FROM MYELITIS. 

4. Very frequently the paralysis 



is complete. 



5. The degree of paralysis the 
same in the various muscles of the 
lower limbs. 

6. Reflex power often lost ; or 
sometimes much increased. 

7. Bladder and rectum usually 
completely paralyzed, or nearly so. 

8. Always spasms, or, at least, 
twitchings. 

9. Always some degree of pain 
existing spontaneously, or caused 
by external excitations. 

10. Usually a feeling as if a cord 
were tied tightly around the body 
at the upper limit of the paralysis. 

11. Always formications, or 
pricking, or both, and very often 
sensations of pricking or heat or 
cold. 

12. Anaesthesia very frequent 
and always at least numbness. 



13. Gastric digestion good, un- 
less the myelitis has extended high 
up in cord. 

14. Ameliorations very rare, and 
not following changes in condition 
of the urinary organs. 



DISEASES OF THE NERVOUS SYSTEM. 



11/ 



PARAPLEGIA {Continued). 



FROM REFLEX IRRITATION. 

15. Usually the urine is acid, 
unless the urinary organs are dis- 
eased. 

16. Cure of the paralysis fre- 
quently and rapidly obtained, or 
taking place spontaneously after a 
notable amelioration or cure of the 
genito-urinary affection. 

17. Usually muscles do not be- 
come atrophied, and temperature 
is little lowered. 

18. Therapeutic results good. 



FROM MYELITIS. 



15. Urine almost always alka- 
line. 



16. Frequently a slow and grad- 
ual progress towards a fatal issue, 
and rarely a complete cure. 



17. Atrophy of muscles of the 
paralyzed parts. 

18. Treatment of little benefit. 



Mr. Gowers divides spinal lesions, according to the time required in 
their development, into six classes, whose comparative features are 
shown in the following table : 

Sudden {few minutes). \ Vascular lesions. 

Acute (few hours or days). J ~) ' 

(Sub-acute (one to four weeks). ! Inflammation (mye- 

Sub-chronic (one to two months). f litis). 
Chronic (two to six months). 1 n 

\r u ■■■•■ v ■ -1 1 J j\ } -Degeneration. 

Very chronic (six months and upward). J fa 



Pressure 

or 
Growths. 



He recommends, in examining a case of disease of the spinal cord, 
to follow a definite plan. " First endeavor to ascertain the exact seat 
of the lesion ; note how far the several conducting functions of the 
cord are impaired, and the highest level of their impairment; then 
ascertain the condition of the central functions, and especially muscu- 
lar nutrition, and irritability and reflex action (first in the part below 
the level at which conduction is impaired and secondly, at the sup- 
posed level of the lesion; and in this way you may infer, without much 
difficulty, what is the extent of the lesion transversely and vertically). 
In the next place, endeavor to ascertain its nature by considering, first, 
how the symptoms came on and developed ; secondly, which of the 
lesions having this onset and development are common in the region 



: : : differential diagnosis. 

affected; and, thirdly, which of them are produced by the cause or 
ch the disease is apparently due." 

Sentr =: : :":r:::s ::" paralysis require sepa-a:e iiscnssi:n. 

psevI':-hy?ertr:?h:c paralysis. 

This is a disease of children, usually attacking them after the ft:- 

cni year ::' life. - 1 -: this ::: : f it is thuni that v.- her. :l:ey are placed 
up::; their fee: they fall ::".:. ;r clutch a: the nearest :: e:t :: sup- 
port themselves ; or in other cases it may be that the child has com- 
menced to walk, when, without pain or fever, or sometimes after 
convulsions, it is found to be soon fatigued, either by walking or 
standing, and at length it can no longer walk or hold itself upright ; 
again, it may be that the child does not walk until very late — 2)4 
or three years — and then very feebly and imperfectly. 

In the advanced stage the child is unable to rise from the floor in 
the ordinary manner. He drags himself up with his hands ; or if he 
be lying down and no support be forthcoming, he gets upon his hands 
and knees, and then, grasping each thigh alternately, is able to raise 
himself sufficiently from the floor to get first one and then the other 
foot upon its sole. He then lays hold of his thighs with successive 
g asps, one above the other, and thus, as it were, climbs up them to a 
standing p:s::::n. This meth : a :f getting ::; the feet is path:gn:n::r.i: 
of pseudo-hypertrophic paralysis.* 

Sj mptoms. — The principal morbid pi e : : : e d a are Duchenne : 

1st. In the begirt:: r.g feebleness :f the l:v.er lintbs. 

2a. Lateral balancings ::" the trunk ana v.ifening :f the legs it 
walking. Inability to raise up on the toes when standing. 

:i A peculiar :urvacure :f the spine ensellure :: saiile-bacl: 
: rdosis), both in walking and standing. 

4th. Equinism (talipes equinus), with a peculiar over-extension of 
the first phalanges of the toes, which Duchenne calls "griffe des 
orteils." 

5 th. Apparent muscular hypertrophy. 

6th. Stationary condition. 

* Nervous Diseases and their Diagnosis. Bt H. C. Wood, M. D., Pbl!a_, 1 8 _ 



DISEASES OF THE NERVOUS SYSTEM. I 1 9 

7th. Generalization and aggravation of the paralysis. 

8th. Patellar-tendon reflex abolished in advanced stage. No paraly 
sis of the bladder or rectum. 

When the disease has arrived at the stage of apparent hypertrophy, 
the appearance of the patient is very characteristic, and its true nature 
would be at once obvious to any one who had any knowledge of its 
symptoms ; but in the earlier stages there is but little to guide us to a 
diagnosis unless we have some hereditary history. Of the hereditary 
nature of this affection the published cases give ample proof. 

There are apparently two forms of this disease — one of spinal, the 
other of muscular origin. 

PARALYSIS, FROM LEAD POISONING AND HYSTERIA. 

In this form of paralysis the usual diagnostic symptoms, to wit, a 
history of exposure to lead, the blue line on the gums, constipation, 
and colic, may all be absent; hence the diagnosis must rest upon the 
peculiar characters of the palsy — especially the effects of electric cur- 
rents upon the muscles. These are the only reliable evidences of the 
nature of the disease. These characteristic reactions, first described 
by Duchenne, are as follows : 

Excitability to faradaism absent or sensibly diminished in all the 
muscles of the forearm except the supinators longus and brevis. In 
health the supinator brevis cannot be directly faradized, on account of 
its deep position. But in lead palsy it very often happens that the 
wasting of the extensor communis digitorum has proceeded far enough 
to uncover the supinator brevis sufficiently to allow a small rheophore 
to be applied to it in the space of about a square inch at the upper and 
back part of the forearm. If it be found (both arms being affected) 
that the common extensor fails to respond to faradaism while the short 
supinator close by, on a lower plane, is readily excited by it, the case 
may be positively set down as one of lead palsy. 

Hysterical Paralysis, in spite of its frequent close imitation of the 
organic forms, is readily diagnosed by attention to the following 
points: 

I. In hysterical hemiparesis the face is rarely, and the tongue never, 
affected. 



120 DIFFERENTIAL DIAGNOSIS. 

2. In hysterical paraplegia incontinence of urine is never present 
(Hamilton). There may be retention or temporary suppression of 
urine. 

3. No amount of help can keep the patient from staggering or fall- 
ing when she attempts to walk (Reynolds). 

4. The foot in walking is simply dragged along, and not swung, as 
in organic hemiplegia (Todd). 

5. In all sudden cerebral palsies, the nails of the affected extremities 
cease to grow. In hysterical palsies, of one limb or both, whether 
paraplegic or hemiplegic, the rate of nail growth is unaltered. (Weir 
Mitchell). 

GENERAL PARALYSIS OF THE INSANE. 

This curious disease, long unknown in the United States, has of 
recent years been frequently observed in the Northern and Eastern 
States, but so far, rarely or not at all in the South and West. It is a 
disease of advanced life, whose pathognomonic characteristics are con- 
stant troubles of motility, a progressive loss of mental power, and a 
constant belief on the part of the patient that he is perfectly well, and 
in the enjoyment of magnificent fortune and gigantic powers {delires 
des grandetirs). 

The following are the progressive traits of the disease as generally 
observed : 

Psychical Symptoms. — 1. General restlessness and unsteadiness of 
mind, with impairment of attention; alternating with apathy and drow- 
siness. 

2. A change in disposition and temper, and a general loss of self- 
restraint; at first as regards trivial social observances, and then as re- 
gards general conduct. 

3. Impairment of the reflective powers, so that there is no logical 
and systematic development of thought. 

4. General exaltation of thought, with a profusion of remembered 
images and ideas, and numerous extravagant desires. 

5. Failure of memory and forgetfulness; at first of words, and then 
of events. 

6. Delirious conceptions, and the transformation of desires into be- 



DISEASES OF THE NERVOUS SYSTEM. 121 

liefs, these being generally connected with personal greatness and 
power. 

7. Hallucinations of the senses, in which remembered sense impres- 
sions are so vivid and intense as to spread to the periphery. 

8. Maniacal restlessness and excitement, in which present impulses 
and feelings instantly pass over into action. 

9. Increased mental weakness, with the incoherent and fragmentary 
repetition of the false ideas previously entertained. 

10. Failure of the senses, with more marked impairment of memory. 

11. Complete fatuity, passage into coma and death. 

Motor Symptoms. — I. Persistent contraction of the occipito-frontalis 
muscle, and some dilatation of pupils, causing the eyes to be widely 
opened and the forehead wrinkled, and giving an expression of sur- 
prised attention to the face. 

2. Persistent contraction and frequent tremors of the zygomatic 
muscles, giving a pleased and benevolent expression of countenance. 

3. Slight muscular restlessness and unsteadiness. 

4. Impairment of the power of executing fine and detailed move- 
ments, so that manipulative skill is lost while movements eri masse are 
still well performed. 

5. Fibrillar tremors of the tongue, and some loss of control over its 
movements, so that it is protruded with difficulty; is rolled about when 
protruded, and is suddenly withdrawn. 

6. Twitchings of the nostrils and upper lip, with frequent tremors of 
the latter. 

7. Impairment of articulation, which is thick and wanting in dis- 
tinctness. 

8. An alteration in the voice, as well as thickness and hesitancy in 
speech. 

9. Loss of control over the combined movements of the hand and 
wrist, so that the handwriting generally deteriorates. 

10. Changes in the pupils, which are at first irregularly contracted, 
and then become irregularly dilated. 

11. An alteration in gait, which becomes unsteady; the more com- 
plex movements of the thigh, leg, and foot, and the balancing of the 
pelvis on the hip joints, being performed with difficulty. 



122 DIFFERENTIAL DIAGNOSIS. 

12. General muscular agitation and restlessness. 

13. Gradual loss of power in the muscles of the face, tongue, neck, 
and limbs. 

14. Spasmodic contraction of the masseter muscles,' causing grind- 
ing of the teeth. 

15. Convulsive seizures — most marked on one side of the body, and 
followed by transitory hemiplegia. 

16. Loss of control over the sphincters. 

17. Complete prostration of muscular strength and helplessness, and 
difficult deglutition. 

18. Contractions of the muscles of the limbs, and paralysis of the 
muscles of respiration. 

The main diagnostic difficulty is to distinguish this from some 
phases of locomotor ataxy. The differences are that in general par- 
alysis the mental symptoms are always present, and always precede 
the motor phenomena. The first symptoms in general paralysis are 
chiefly cerebral ; viz., mental excitement, great garrulity, noisy hilar- 
ity, bragging, early violence of behavior, and very usually some ex- 
hibitions of libidinous conduct; on the subsidence of excitement, the 
mind is found to be weak, and the motor phenomena gradually make 
their appearance. 

In ataxia, the commencement is in the spinal functions. There is 
first an attack of pain of some remote part, occurring most frequently 
in the lower extremities, and dating several years back, considered at 
the time perhaps to be rheumatic ; this pain is worse toward evening, 
or when the patient is not mentally occupied ; it may improve or dis- 
appear for a time and return. Then follows a slight degree of numb- 
ness of the part ; the patient feels as if he had trod on wool ; occa- 
sionally " pins and needles " attack the part ; in fact, those phenomena 
which we have all experienced after sitting in an awkward position, 
when one's own leg has "gone to sleep." There is, as most of us 
know, want of feeling, want of recognition of the member, especially 
as to its size, and even its ownership, then atrocious pain, and formica- 
tion or "pins and needles." In this disease, on the subsidence of the 
pain, the patients exhibit some awkwardness in gait; the ataxy or 
want of order in the movement is evident, while vigorous muscular 



DISEASES OF THE NERVOUS SYSTEM. 



12 



movements can still be executed. These symptoms may extend over 
ten or twelve years with very little change, except, perhaps, increasing 
awkwardness in gait ; there is doubtless some numbness of the cutan- 
eous surface in the course of the disease ; the phenomena appear to 
spread upward by involving the functions of the nerves higher up ; 
the power of erection of the penis, and soon after the sexual appetite, 
are lost, and, as the disease ascends, the expulsory power of the blad- 
der and rectum become impaired. All this occurs in most cases while 
little change takes place in the mental functions; but in other cases 
the mind appears imbecile, the memory is affected, and there is distinct 
alteration in behavior and conduct; but there are no lofty ideas, no 
excessive excitement and garrulity, and in no case paroxysms of vio- 
lence, or libidinous ideas. 

The differences may be better seen in a tabulated form : 



GENERAL PARALYSIS. 
Runs its course in a few years. 

Commences with mental symp- 
toms. 

Is attended with libidinous ideas. 

The motor symptoms are sec- 
ondary in the order of time. 

Is only rarely complicated with 
pelvic difficulties. 

There often is great violence of 
conduct. 



LOCOMOTOR ATAXY. 

Is much slower usually, and may 
last ten or even twenty years. 

Commences with pain in distal 
nerves. 

Is attended with abolition of 
sexual feeling. 

The motor symptoms are the 
primary phenomena. 

Pelvic symptoms are a promi- 
nent feature. 

The mental phenomena are im- 
becility and impaired memory. 



There is also a form of general paralysis due to syphilis. The dif- 
ferential features of this variety have been clearly defined by Dr. E. C. 
Seguin.* We do not obtain the regular gradations and stages of the 
true disease. The moral perversion which is peculiar to general par- 
alysis is absent, neither do we see the pure, exalted notions. The 



* Hospital Gazette, September, 1878. 



124 



DIFFERENTIAL DIAGNOSIS. 



fibrillary tremors that are so well marked in general paralysis are not 
present here. The articulation is more mumbling in character. We, 
likewise, are apt to have a great deal of actual paralysis of cranial 
nerves or body in these cases. In true general paralysis, after attacks 
of hemiplegia, the patient regains his full strength, whereas this is not 
apt to occur in the syphilitic variety. The following table will perhaps 
show clearly the main differences : 



TRUE GENERAL 
PARALYSIS. 

Prodromic stage. 

Exalted notions, numerous and 
varied, and relatively exalted ac- 
cording to the position in life. 

Speech is tremulous and jerky. 

Tremor of hands and lips. 

Preservation of strength. 

Pupils are apt to be contracted. 

None. 

None. 

Transient aphasic attacks. 

Spontaneous remissions. 



SYPHILITIC GENERAL 
PARALYSIS. 

Absent. 

Rare or absent. 



Speech is thick. 

Absent as a rule. 

Paresis or actual paralysis. 

Apt to be open or wide. 

Palsy of third or of other cranial 
nerves. 

Headache nocturnal. 

More serious aphasic attacks. 

Progressive except under treat- 
ment. 



Some other differences between the two conditions are as follows : 
The patient with syphilis has none of the cravings or abnormal appe- 
tites of the other; the latter fjels an impulse to get drunk or to have 
an excess of coition. The tendency to excessive coition is absent in 
syphilitic paralysis, and, indeed, there is a marked loss of the virile 
power. The temperature changes are also absent in syphilis of the 
brain. The rise in temperature in general paralysis of the insane is 
very great, often reaching 103 ° in exacerbations. There is no rise of 
temperature in syphilis of the brain, except, perhaps, when the patient 
has hemiplegia from a large lesion. 



DISEASES OF THE NERVOUS SYSTEM. 125 

The most important point is, that in syphilis there is a paralysis; in 
general paralysis there is irritation and incoordination without true 
paralysis. 

SPINAL HYPERESTHESIA, SPINAL IRRITATION 
(so-called), AND SPINAL WEAKNESS. 

This affection has been described by some writers as spinal hyper- 
emia, by others as spinal anaemia; again as spasms of the spinal mus- 
cles, and lastly as abnormality of the spinal cells. Some have denied 
its existence altogether; but in fact it is a distinctly defined and not 
unusual disorder. About five-sixths of the cases are neurotic females, 
and it is often associated with uterine or ovarian disease ; and as often 
has some antecedent history of a blow upon or other slight injury to 
the spine. 

Its symptoms are of the most varied kind, so much so that it may 
simulate almost every known ailment; but a careful examination of the 
spine will reveal its true character. The diagnostic rules laid down by 
Drs. William and David Griffin, in 1834, who first described the 
disease, have never been improved upon. They are as follows. 

1. The pain or disorder of any particular organ complained of is 
altogether out of proportion to the constitutional disturbance. 

2. The complaints, whatever they may be, are usually relieved by 
the recumbent position, are always increased by lifting weights, bend- 
ing, stooping, or twisting the spine ; and among the poorer classes are 
often consequent to the labor of carrying heavy loads, drawing water, 
etc. 

3. The existence of tenderness at that point of the spine which cor- 
responds to the disordered organ, and the increase of pain in that 
organ by pressure on the corresponding region of the spine. 

4. The disposition to a sudden transference of the diseased action 
from one organ or part to another, or the occurrence of hysterical 
symptoms in affections apparently acute. 

5. The occurrence of continued fits of yawning or sneezing. These 
are not very common in the disease, but when they do occur, they 
may generally be considered as characteristic of nervous irritation. 

To this it may be added that the tenderness may extend along the 



126 DIFFERENTIAL DIAGNOSIS. 

spine generally, but is always greater in one or two spots. Gastric 
symptoms,' headache and languor are usually well marked in spinal 
irritation; but there is neither muscular spasm, atrophy, paralysis (ex- 
cept hysterical) nor waist constriction, which serve to distinguish it 
from a large class of spinal diseases. 

In regard to the nature of spinal irritation, we know nothing definite 
at present (Erb). Wood declares that " there is not the slightest evi- 
dence of anaemia or congestion, or of any other recognizable spinal 
irritation."* Lumbago, omodynia, scapulodynia, dorsodynia (forms 
of myalgia), should be distinguished from spinal hyperaesthesia, though 
often confounded with it (see page 1 36.) 

NEURASTHENIA. 

Neurasthenia is generally classed among the so-called "functional" 
affections of the nervous system. Beard, however, in his original 
paper upon the subject, distinctly stated his conviction that there are 
definite structural alterations, although perhaps undetectable, in the 
nervous system, underlying the functional disorders which furnish the 
varied manifestations of neurasthenia. That this neurasthenic condi- 
tion may eventuate in various grave or even fatal disorders is now be- 
coming more generally recognized, and the views expressed by Beard 
nearly twenty years ago are daily obtaining more favorable considera- 
tion. 

Arndt| has proposed a new theory of the ultimate or underlying 
cause of neurasthenia. According to his theory, neurasthenia is in 
all cases due to a- defective nervous organization, the nervous supply 
being inadequate to perform the functions demanded by the physical 
organism, of which it is respectively a part. In some instances the 
disproportion between nervous and non-nervous tissue may be so 
slight that no disorder results until excessive demands are made upon 
the nervous power, or until some grave interference with general nutri- 
tion — i. e. y some depressing disease, injury, or other cause of mal- 
assimilation — makes the inequality more prominent. These are the 
cases which usually manifest themselves decidedly for the first time in 

* Nervous Diseases and their Diagnosis. Phila., 1887, p. 284. 
f Die Neurasthenie, Wien, 1886. 



DISEASES OF THE NERVOUS SYSTEM. 127 

advanced life in the broken-down business and professional man, bank- 
rupt of nerve-force, of which this country has so large a proportion, 
and which seem to justify Beard's designation of neurasthenia as a 
distinctively American disease. So long as food is well digested, the 
blood properly oxygenated, the products of retrograde metamorphosis 
removed from the system by normally-acting emunctories, and the 
brain allowed intervals of recuperating rest, the individual does not 
become neurasthenic. But when any one or more of these conditions 
fail of attainment, the shortcomings of the defective nervous organiza- 
tion become apparent after a shorter or longer interval. 

If, on the other hand, the original disproportion between the nervous 
system and the rest of the organism is great, the evidences of neuras- 
thenia are early manifested — either in infancy, in childhood, at puberty, 
or during adolescence. 

The trivial importance attached to neurasthenia by the majority of 
general practitioners often results in serious harm to the afflicted indi- 
viduals. The diagnoses of hysteria, hypochondria, or syphilophobia, 
so frequently heard in our clinical amphitheatres, are responsible for 
much of the flippancy with which many of these heavily-burdened 
patients are treated. Lightly to accuse a woman of being " hysteri- 
cal," or a man of being " hipped," may often be the gravest injustice, 
attaching, as it does, a stigma to the patient which may lead to perma- 
nent valetudinarianism, or even to self-destruction. Dr. Emmet has 
shown, by his brilliant clinical studies upon the consequences of neglect 
of certain lacerations of the cervix uteri, how many cases of so-called 
hysteria are dependent upon a purely physical condition of the nerves 
involved in the laceration. In the light of present knowledge, the 
nervous symptoms of laceration of the cervix uteri must be considered 
as expressions of the lack of nerve -power. 

The manifestations of neurasthenia, diverse as they are in causation, 
are no less frequent than bewildering in their multiformity. Cases 
now and then occur characterized by general indisposition, vague 
nerve, muscle, or bone-pains, loss of appetite, sleeplessness, depression 
of spirits, frequent attacks of sick-headache, lack of the power of sus- 
tained intellectual application, and similar symptoms not referable to 
any special organ or apparatus. In other cases the languid or semi- 



128 DIFFERENTIAL DIAGNOSIS. 

paretic condition is replaced by nervous exaltation or irascibility. In 
fact, both conditions may characterize the same case at different times. 

These cases might with propriety be called cerebro-spinal neuras- 
thenia. They are exceedingly troublesome to manage, and in many 
instances terminate in insanity or structural disease of the spinal cord. 
The gradual change from soundness to unsoundness of cerebral and 
spinal functions in these cases is well described, by Blandford* and 
Arndt.t 

The most marked forms of cerebro-spinal neurasthenia result from 
extreme nervous exhaustion from any cause. Intense intellectual ap- 
plication in persons with a neurasthenic predisposition — in other 
words, with a primarily defective nervous organization — frequently 
determines an outbreak. Many of the leading writers, artists, and 
public men of the day belong to this class. Among the more promi- 
nent neurasthenics of the present century were Walter Savage Landor, 
Carlyle, Dante Gabriel Rossetti, Richard Wagner, and Victor Hugo. 
In this country two of the most distinguished women writers have 
recently suffered to an extreme degree from cerebro-spinal neuras- 
thenia. 

Many of these cases can be immediately traced to some traumatism, 
an especially large number being the consequence of railroad injuries. 
Mr. Erichsen and Dr. Beard have both described a number of such 
cases in detail. In the sad case of the American poet, John G. Saxe, 
now a confirmed victim to melancholia, the origin of the disease was 
a spinal concussion received in a railway accident. The methods of 
studying the brain recently developed by M. Luys will doubtless en- 
large our knowledge of the more intimate nature of the processes con- 
cerned in the evolution of morbid psychic and motor manifestations 
resulting from traumatism. 

Neurasthenia as effect, and probably in a measure also as cause, 
of local alterations of nutrition, is extremely frequent. The manifold 
reflex symptoms of disturbances in the genito-urinary system are sim- 
ply manifestations of neurasthenia. Lallemand, Acton, Beard, S. W. 
Gross, Moreau, Howe, Hammond, Von Krafft-Ebing, Tarnowsky, 

* " Insanity and its Treatment," Lecture III. 
f Loc. cit., pp. 171-202. 



DISEASES OF THE NERVOUS SYSTEM. 120, 

Ultzmann, and, above all, Otis, have shown the very intimate connec- 
tion between genito-urinary diseases in the male and nervous exhaus- 
tion. Not merely did the profound original researches of Otis point 
out the connection between urethral stricture and many nervous symp- 
toms previously misunderstood, but his practical ingenuity gave to the 
profession a ready means of cure. Dr. Sayre has shown the etiologi- 
cal relations of adherent prepuce to epileptoid conditions, and has 
likewise indicated the methods of relief. In the writer's experience, 
an elongated and phimotic prepuce has not rarely seemed to be the 
cause of the train of symptoms comprised under the designation 
spermatorrhoea. At all events, the simple dorsal division of the pre- 
puce has seldom failed to check promptly the frequent involuntary 
emissions and render the nervous symptoms amenable to appropriate 
treatment. In one marked case of pathophobia, under treatment two 
years ago, the symptoms seemed to be attributable to a frequently- 
recurring, herpes-preputialis. At all events, improvement in the psy- 
chic condition progressed pari passu with relief of the local disorder. 

The female sex is probably subject to neurasthenia from sexual dis- 
orders to a still greater degree than the male. Emmet's epoch-mark- 
ing investigations into the consequence of laceration of the cervix 
uteri show most conclusively the powerful influence of local nerve- 
lesions is the production of neurasthenia. Trustworthy authorities 
have stated that mental alienation may result from a continuance of 
marked neurasthenic symptoms. During a term of service in the 
Maryland Woman's Hospital and in many cases in private practice, 
the writer has had opportunities to observe the rapid disappearance of 
the symptoms of nervous depression after appropriate local treatment. 

Again, the manifold neurotic symptoms which attend attacks of 
chronic oophoritis or pelvic peritonitis and cellulitis, and which not 
rarely eventuate in insanity, are evidences of neurasthenia depending 
upon local pathological conditions. A recent clinical contribution by 
Moritz Meyer,* calls attention to the frequency with which certain 
neuroses are dependent upon local neuritic affections, and points out 
the appropriate remedy. 

* Berliner Klin. Wochenscrift, October 25, 1886. 



130 DIFFERENTIAL DIAGNOSIS. 

Mr. H. B. Hewetson* has also reported a number of cases of gen- 
eral neuroses due to eye-diseases. It is, of course, not pretended that 
all the cases of general neurotic disorder depending upon local affec- 
tions are properly called neurasthenia; but the relation is much more 
frequent than is generally believed. . 

On the other hand, a neurotic or neurasthenic constitution may be 
responsible for the intensification, if not also for the origin, of the local 
disease. This is unquestionable in certain of the disorders of the 
genito-urinary apparatus in both sexes. Involuntary seminal emis- 
sions and functional impotence are notoriously frequent consequences 
of a lack of nerve-force. In women, ovarian irritability, amenorrhcea, 
and dysmenorrhoea can often be referred to the same source. 

It looks very improbable at first sight that new- growths, especially 
cancer, should be rationally attributable to the influence of nervous 
depression. However, so acute an observer as Sir James Paget seems 
to incline to the view that such a relation may possibly exist. Snowt 
states that of one hundred and forty cases of mammary cancer ana- 
lyzed by him, "one hundred and three gave an account of previous 
mental trouble, hard work, or other debilitating agency." Of one 
hundred and eighty-seven cases of uterine cancer, nearly one-half 
(ninety-one) gave a similar history*. A number of detailed histories 
given by this author seem to bear out the claim that mental depression 
(neurasthenia 1 is a frequent cause of cancer. Arndt? is positive that 
neurasthenia is an etiological forerunner of cancer, and relates three illus- 
trative cases. Willard Parker! J states that "there are the strongest 
physiological reasons for believing that great mental depression, par- 
ticularly grief, induces a predisposition to such a disease as cancer, or 
becomes an exciting cause under circumstances where the disease had 
already been acquired." In over one-fourth of Parker's cases of can- 
cer of the breast (one hundred and six out of three hundred and 
■ninety-seven), nervous depression or conditions directly leading to it are 
set down as forerunners of the disease. 

* London Lancet, November 27, 18S6. 

7" Clinical Notes on Cancer,"' London, 1SS3. p. 30. 

% Die Neurasthenic, Wien, 1SS6, pp. 202-20S. 

" On Cancer/' New York, 1885. pp. 40-43 and 58. 



DISEASES OF THE NERVOUS SYSTEM. I3I 

Cooke* points out the fact that in women cancer occurs on an 
average ten years earlier than in men, coinciding in the former sex 
with the menopause, and in the latter with the period of greatest ex- 
haustion of the nervous system. He remarks that " the women of 
fifty are very generally more worn and wasted than the men of sev- 
enty." It is between the fiftieth and sixtieth years that neurasthenia 
from professional overwork is most frequent. The merchant, official, 
or professional man is reminded that he cannot do the same amount of 
work at fifty that he could at thirty ; in the words of a distinguished 
Philadelphia teacher of the last generation, " he cannot get a three- 
minute pace out of a four- minute horse." 

Jonathan Hutchinson f says upon the same point : " We shall prob- 
ably be not far from the truth if we admit senility of tissues, local or 
general, to be the one predisposing cause of cancer with which we are 
acquainted A little step further may next be taken, in the be- 
lief that everything which hastens senility, either local or general, will 
increase the predisposing influence, and in this category may be placed 
anxiety, distress, overwork, and excesses of all kinds. It is highly prob- 
able that under such conditions a state involving increased proneness to 
cancer may be induced, and, further, that if offspring are produced after 
that state has been developed, they wril inherit that tendency!' 

Parker, in commenting upon the unfriendly attitude of modern mi- 
croscopical pathologists towards the theory that derangements of the 
nervous system may determine the origin of cancer, makes the wise 
observation that too close attention to the revelations of the micro- 
scope may obscure our view into the conditions underlying the visible 
changes. The question certainly deserves more unprejudiced study 
than it has heretofore received. 

Disorders of the digestive system are intimately related to neuras- 
thenic conditions. Even in persons with no demonstrable inherited 
nerve-weakness, any great depression of the assimilative organs re- 
sults in a passing neurasthenia. Gastric or intestinal. catarrhs, or dis- 
orders of the liver, or an overloaded condition of the large intestine,^ 

* " On Cancer," London, 1865. 

X" The Pedigree of Disease," New York> 1885, p. 74. 

\ J. S. Jewell, in Neurological Review, vol. i., No. 4, p. 218 et seq. 



132 DIFFERENTIAL DIAGNOSIS. 

if long continued, are nearly always accompanied by neurasthenia. 
Where there is an inherited neurasthenic constitution, the digestive 
troubles are doubtless sometimes the consequence of a foregoing- ner- 
vous depression. Every practitioner sees such cases almost daily ; 
but the relations between cause and effect often remain unrecognized. 
The sub-diaphragmatic self-consciousness of Carlyle was doubtless of 
this nature. The loss of digestive power, insomnia, mental irascibility, 
and unmanly treatment of his wife and friends, which characterized 
his later life, all point to an inherited neurasthenic predisposition. 
Some of these characteristics were still more pronounced in Walter 
Savage Landor.* 

The frequency of the diagnosis of " nervous dyspepsia" is an indi- 
cation that a tendency to attribute to the nervous system a share in 
the production of painful digestion is gaining ground. However, as 
Dr. Clifford Allbutt clearly pointed out in the Gulstonian Lectures for 
l884,f what is so commonly called nervous dyspepsia, is not really 
dyspepsia or gastric disorder at all, but a manifestation of neurasthenia, 
curable only by appropriate treatment directed to the nervous system. 
Drs. S. Weir Mitchell J and Richard M. Hodges || have also point- 
edly called attention to the customary lack of accuracy in the diagno- 
sis of these cases, and have given many judicious hints for their man- 
agement^ 

In making a diagnosis, these characters will be distinguished from 
those of disease of the vertebrae by careful physical examination, and 
the age, sex, and history of the case. 

HYSTERIA. 
Few diseases present at times greater difficulties of diagnosis than 
this protean complaint. Its counterfeits of various maladies will be 
considered elsewhere (see the Index) ; at present we shall seek for a 
pathognomonic symptom of the general condition. 

* " Landor," by Sidney Colvin. New York, 1881. 

f " The Visceral Neuroses," Philadelphia, 1884. 

J " Fat and Blood," and " Nervous Diseases of Women." 

|| Boston Medical and Surgical Journal, July 10, 1884. 

\ George H. Rohe, Philadelphia Med. Times, vol. xvii., p. 284. 




DISEASES OF THE NERVOUS SYSTEM. 133 

One is offered by Dr. Thomas Barlow.* Rejecting as unsatisfac- 
tory all statements depending upon the patient's veracity, he finds a 
diagnostic test in the presence of analgesia. If, while the patienfs at- 
tention is directed to something else, a needle be introduced into the 
forearm, and no wincing occurs, there is the strongest presumption 
that we have to do with a case of hysteria. Again, it has been long 
known that hysterical patients are often extremely tolerant of laryngo- 
scopy examination. Great advantage will be found in examining a 
presumed hysterical patient's larynx, and thus fixing her attention 
while somebody at the same time inserts a needle in her forearm. Ab- 
solute tolerance of these two simple methods of examination is quite 
decisive. 

Another characteristic relates to the pain so frequently complained 
of. While it is stated to be exceedingly acute, and the part tender to 
the slightest pressure, if the attention of the patient is engaged, very 
firm pressure may be made without the patient wincing. Moreover, 
there is noted very often a co-existence of severe pain in the epigas- 
trium, the left side and spinal column — the trepied hysterique, or hys- 
terical tripod of French authors. 

The globus hystericus, a sensation of a foreign body in the throat 
caused by spasmodic contraction of its muscles, is a common symp- 
tom. The urine may be suppressed, or may be limpid and watery, 
and of unusual quantity. 

If with these traits are united youth and female sex, and fairly main- 
tained nutrition ; ovarian or uterine disturbance ; the general symp- 
toms harmonious and exaggerated ; the mind clear ; and the disappear- 
ance of contractions, etc., under anaesthesia; the diagnosis is complete. 

The most serious mistake would be the confounding of a hysterical 
paroxysm with an epileptic fit. The following table of distinctions 
between the two is given after Charcot and Da Costa: 

EPILEPSY. HYSTERIA OR HYSTERO- 

EPILEPSY. 
Gradual or only partial or ap- 
parent unconsciousnes. Patient 
rarely falls so as to injure herself. 



Sudden and complete loss of con- 
sciousness. Patient liable to injure 
herself in falling. 



* Medical Times and Gazette, February, 1878. 



34 



DIFFERENTIAL DIAGNOSIS. 



EPILEPSY. 

Livid face; escape of frothy sa- 
liva from the mouth ; eyelids half 
open; eyeballs rolling; grinding of 
the teeth ; biting of the tongue ; 
more or less insensibility of the 
pupils to light. 

Distortion of countenance. 

Patient evinces no feeling. 

Aura epileptica of short duration. 

Convulsions often more marked 
on one side than on the other; and 
more tonic than clonic. Agitation 
maniacal and disorderly. 

Paroxysms generally of short 
duration. 

Paroxysm followed by a heavy, 
half comatose sleep, by headache, 
and dullness of intellect. Stertor. 
No hallucinations. 

Frequently occurs at night. 

No particular connection with 
uterine disturbance: although a 
paroxysm often takes place at the 
menstrual period. 



HYSTERIA OR HYSTERO- 
EPILEPSY. 

Face flushed or complexion un- 
altered ; no froth on lips; eyelids 
closed; eyeballs fixed; neither 
grinding of the teeth nor biting of 
the tongue ; pupils react readily. 

No distortion of countenance. 

Patient sighs, or laughs, or sobs. 

Aura often prolonged one or 
two days. Globus hystericus. 

No such differences; convulsions 
clonic. Agitation emotional, often 
en pose. 

Paroxysms generally of longer 
duration. 

Paroxysm not followed specially 
by sleep; patient often, after at- 
tack, wakeful and depressed in 
spirits. Little or no stertor. Hal- 
lucinations. 

Rarely occurs at night. 

Often connected with disorders 
of the uterus, or of menstruation. 



The distinctive characters of tetanus, convulsive hysteria, and simi- 
lar diseases are shown in the following- table : * 



TETANUS. 

Commences with 
malaise, muscular 

twitchings, rigidity, 
and tenderness. 



HYSTERIA. 



POISONING BY 
STRYCHNINE. 



Blindness and weak- Exhilaration 
ness may usher in an restlessness. 

I 



and 



attack. 



TETANY. 



Numbness and tin- 
gling in fingers and 
toes, followed by 
tonic spasm of limb. 



* Partly from H. C. Wood's Therapeutics. Sixth Edition, Phila., 1SS6. 



DISEASES OF THE NERVOUS SYSTEM. 



135 



TETANUS. 

Muscular symptoms 
gradually become 

more prominent. 

Lock-jaw an early 
symptom. 



Persistent rigidity 
with tendency to opis- 
thotonos, empos tho- 
nos, pleurosthotonos, 
or orthotonus. 

Consciousness un- 
affected. 



Draughts of air, sud- 
den noises, etc., excite 
convulsions. 

Complains of pain. 



Eyes open and star 
ing through convul- 
sions. 

Recovery rare, gen- 
erally fatal in first at- 
tack. 



HYSTERIA. 

Not limited to cer- 
tain muscles; jaw not 
permanently set. 



Opisthotonos persis- 
tent, and intense rigid- 
ity between convul- 



Lost during convul- 
sions. 



Not the case. 



Hysterical sobbing 
and crying. 

Eyes closed. 



Recovery the rule; 
attacks likely to recur. 



POISONING BY 
STRYCHNINE. 
Early muscular 
twitcbings or general 
convulsions. Jaw af- 
fected late. 



Muscles relaxed 
between paroxysms ; 
soreness and stiffness 
after convulsions have 
ceased. 

Generally preserved 
during convulsions, 
unless asphyxia 

should occur. 

The slightest breath 
of air causes convul- 



Screams with pain 
when convulsions oc- 
cur. 



Eyes 
opened. 



widely 



Attack single, and 
likely to be fatal. 



TETANY. 

Muscular spasm in 
one limb, or several 
successively, of brief 
duration usually, may 
last an hour or two ; 
rarely extends to mus- 
cles of jaw. 

Relaxed. Parox- 
ysms recur at variable 
intervals, may last for 
weeks or months. 

Consciousness un- 
affected. 



Spasms brought on 
by pressure upon 
nerve-trunks or blood- 
vessels. 

Less painful. 



Facial muscles 
rarely involved. 

Prognosis usually 
favorable, the attacks 
subsiding after a few 
months. Occasion- 
ally death occurs from 
asphyxia. 



NEURALGIA. 



The positive signs which distinguish a case of neuralgia, are suc- 
cinctly set forth by Dr. Francis E. Anstie,* as follows : 

(1) The first and most essential characteristic of a true neuralgia is 
that the pain is invariably either frankly intermittent, or at least fluc- 
tuates greatly in severity, without any sufficient and recognizable cause 
for these changes. 

(2) The severity of this pain is altogether out of proportion to the 
general constitutional disturbance. 

(3) True neuralgic pain is limited with more or less distinctness to 
a branch or branches of particular nerves; in the immense majority of 



*" Neuralgia and its Counterfeits," p. 565. 



156 



DIFFERENTIAL DIAGNOSIS. 



cases it is unilateral, but when bilateral it is nearly always symmetri- 
cal as to the main nerve affected, though a larger number of peripheral 
branches may be more painful on one side than on the other. 

(4) The pains are invariably aggravated by fatigue or other depres 
sing physical or psychical agencies. 

These four cardinal points of the diagnosis may be further supported 
by the history of the patient. Either (1) he has previously been neu- 
ralgic, or liable to other neuroses, or comes of a neurotic family; or 
(2) there has been malarial poisoning of the blood; or (3) there has 
been some long-continued peripheral or central irritation; or finally (4), 
there has been constitutional syphilis. 

The pains with which neuralgia is most likely to be confounded, are 
those arising from myalgia, spinal irritation, locomotor ataxia, cere- 
bral abscess, alcoholism, syphilis, chronic rheumatism, and latent gout. 

In comparing the pains of myalgia and neuralgia, the following are 
the more important points : 



NEURALGIA. 
Follows the distribution of a re- 
cognizable nerve or nerves. 



Accompanies an inherited or ac- 
quired nervous temperament which 
is obvious. 

Is usually not much or at all 
aggravated by movement. 

Is at first not accompanied by 
local tenderness. 



Painful points, when established 
in a later stage, correspond to the 
emergence of nerves. 

Pain not materially relieved by 
any change of posture. 



MYALGIA. 

Attacks a limited patch or 
patches that can be identified with 
the tendon or aponeurosis of a 
muscle which, on injury, will be 
found to have been hard w T orked. 

Often occurs in persons with no 
special neurotic tendency. 

Is inevitably and very severely 
aggravated by every movement of 
the part. 

Distinguished from the first by 
localized tenderness on pressure as 
well as on movement. 

Tender points correspond to ten- 
dinous insertions and origins of 
muscles. 

Pain usually completely and al- 
ways considerably relieved by full 
extension of the painful muscle or 
muscles. 



DISEASES OF THE NERVOUS SYSTEM. 



137 



Treatment also offers a diagnostic means. The pains of myalgia 
will sometimes disappear at once by retaining the affected muscle at 
full extension, surrounding it with moist warmth, and giving 20 or 30 
grains of muriate of ammonia internally. 

Spinal irritation (spinal hyperesthesia) is almost exclusively con- 
fined to women. There are nearly always hysterical symptoms, marked 
superficial tenderness over large portions of the surface, often merely 
cutaneous and becoming less acute with firm pressure. There are 
nearly always tender spots along the spine, and also over the epigas- 
trium and the left hypochondrium. 

Locomotor ataxia is mentioned elsewhere, and its symptoms de- 
scribed in sufficient detail. (See page 108.) 

Alveolai abscess is often in its incipient stage mistaken for neuralgia. 

Cerebral abscess, though rare, may give rise to a regrettable mistake, 
especially in its early stages, where severe pain in the head is almost 
the only conspicuous symptom. At this period the diagnosis from 
neuralgia must rest on the following points of contrast: 



CEREBRAL ABSCESS. 

Often occurs secondarily to car- 
ies of internal ear, and purulent 
discharges, the result of scarlet 
fever, measles, etc., in childhood. 

Frequently follows a blow or 
injury. 

No true " points douloureux." 

Usually the pain does not com- 
pletely intermit. 

Pain often excruciating from a 
very early period. 

Pain often limited in situation, 
seems deep-seated, though as often 
as not it has no relation to the site 
of the abscess. 



NEURALGIA OF THE HEAD. 

Rarely appears before puberty. 
No local assignable cause. 



Comparatively seldom Caused by 
a blow or other external injury, or 
caries of the bone. 

If severe, soon presents, in most 
cases, the *' points douloureux." 

Intermissions of pain complete 
and of considerable length. 

Pain usually not very violent at 
first. 

Pain superficial; follows distri- 
bution of recognizable nerve 
branches belonging to the trige- 
minus or great occipital. 



i3« 



DIFFERENTIAL DIAGNOSIS. 



CEREBRAL ABSCESS. 
No well localized vaso-motor or 
secretory complications. 

Very rare in old age; then us- 
ually traumatic. 

Relief from stimulant narcotics 
very transitory. 



NEURALGIA OF THE HEAD. 
Usually lachrymation, or con- 
gestion of the conjunctiva, etc. 

Severe neuralgia is commonest 
in advanced life. 

Relief from opium, etc., is much 
more considerable and permanent. 



The pains of chronic alcoholism often closely stimulate those of true 
neuralgia. The habits and history of the patient, when known, point 
to the true origin of the suffering ; also the insomnia, loss of appetite, 
foul breath, furred tongue and haggard countenance of the drunkard ; 
and especially that the pains complained of encircle the limbs near the 
joints, rather than run longitudinally the course of the nerves in the 
limb, are all significant. 

The osteocopic pains of syphilis are usually symmetrical ; are aggra- 
vated by the warmth of the bed ; are generally referred to the super- 
ficial bones, and do not exist long without some other and decisive 
symptoms of the poison manifesting themselves. 

Chronic. rheumatism and gout are each attended with such marked 
collateral disturbances that the suspicion of their presence can readily 
be set at rest or sustained. 

MULTIPLE NEURITIS. 

Dr. W. R. Gowers, in his recent work (" A Manual of Diseases of 
the Nervous System "), gives a very clear description of this disease, 
which is now attracting so much attention. 

He thinks that the " discovery " of multiple neusitis is one of the 
most important steps in the recent advance of neurology. The morbid 
change may be interstitial (between the fibres), or parenchymatous 
(degenerative change of the fibre itself), or both. He differentiates five 
forms of the disease. 

(i) Diphtheritic neuritis: a parenchymatous degeneration of the 
nerves, associated, however, with disease of other parts. 

(2) Tabetic neuritis: the slow chronic changes in nerve-trunks 
which occur in locomotor ataxia, and which may possibly not be in- 
flammatory. 



DISEASES OF THE NERVOUS SYSTEM. 1 39 

(3) Leprous neuritis: the slow interstitial overgrowth of connective 
tissue which occurs in anaesthetic leprosy. 

(4) Endemic neuritis, as in the Japanese disease called kakke (and 
the more familiar beri-beri?). 

(5) Under this head he places the " other forms of multiple neu- 
ritis," which, indeed, constitute the disease to which the name is 
usually restricted. Gowers finds the disease most common in females, 
which is unexpected when he states that by far the most common 
cause of it is chronic alcoholism. In fact, he uses the terms " alcoho- 
lic paralysis " and " multiple neuritis " as almost identical." Among 
other causes, however, which he admits to be sometimes operative are 
cold, fatigue, rheumatism, phthisis, septicaemia, and exhausting dis- 
eases. 

The pathology may consist either in parenchymatous or interstitial 
changes in the nerve-trunks, but in severe cases probably in both. He 
insists that the fibres are always damaged ; but in. some cases the con- 
nective tissue presents little change. As the trunks are traced upward, 
the evidence of inflammatory changes becomes slighter, and in all 
forms the anterior roots are usually normal. The nerves in the limbs 
alone suffer in the majority of cases, and the affection is bilateral. The 
nerves supplying the extensor muscles of the hand and foot are espec- 
ially liable to attack. Very rarely the phrenic, pneumo-gastric, facial, 
and hypoglossal have been inflamed, the other cranial nerves escaping. 
The muscles usually degenerate, as in simple forms of neuritis. The 
cord is usually normal. The symptoms are the same as follow inflam- 
mation of a single nerve, differing only in their wide range; they are 
especially motor palsy and sensory irritation. The motor palsy, a» 
said above, is apt to be most pronounced in the musculo-spiral and 
anterior tibial nerves. The symptoms are apt to set in acutely, and .to 
be accompanied by rigors and fever. The sensory symptoms come 
first as vague "pins and needles sensations" in fingers and toes, pre- 
ceded perhaps by rheumatoid pains. These pains increase until finally 
the nerve-trunks become tender on pressure, and superficial nerves, as 
the ulnar may be felt to be distinctly swollen. The muscles also be- 
come very sensitive to pressure. Motor palsy supervenes and resembles 
in the arms lead palsy, with the important distinction that the supinator 



I4O DIFFERENTIAL DIAGNOSIS. 

longus muscle is apt to be involved, as it is not in plumbism. In 
severe cases the flexors of the wrist and ankle (hand and foot) also 
become involved, as do also the muscles moving the elbow-, knee-, 
shoulder- and hip-joints. Electro-diagnosis is important. The nerve- 
trunks lose their electrical excitability [probably more completely 
than in some forms of anterior poliomyelitis], and the muscles put on 
the reactions of degeneration. Gowers calls attention to a distinct inco- 
ordination of movement, which it is important to distinguish from 
locomotor ataxia. The sensory phenomena are, briefly, hyperesthesia 
of the extremities, especially of the palms and soles; anaesthesia along 
the radial side of the forearms and outer side of the leg in particular, 
sometimes associated with pain (anczsthesia dolorosa f). Reflex action 
is always lost. Trophic changes and oedema have been observed. 
The duration of the disease varies, but at best it is apt to extend over 
several months. In very severe cases death has occurred from failure 
of the muscles of respiration, especially the diaphragm. An important 
complication is mental impairment, often with delusions, particularly 
in the alcoholic cases. 

INSANITY. 

The principal forms of insanity are commonly considered under the 
head of Mania, Monomania, Melancholia, Dementia, Idiocy and Imbe- 
cility ; to which may be added emotional and impulsive insanity, which 
is now usually admitted. There is no ground for recognizing as a 
distinct variety, moral insanity (Flint), but moral degradation and im- 
moral conduct occur in different forms of insanity, and may constitute 
the earliest observed symptom, as in general paralysis. 

The pathological anatomy of insanity has been thus stated by 
Seguin : 

C (Anaemia. 

Vascular changes < Hyperemia. 

( Serous effusion. 
I. Acute Recent Cases. \ Old congestion. 

Hemorrhages into perivascular sheaths. 

Changes in gray matter (not demonstrable under the micro- 
scope, 
f Congestion of anaemia. 
| Atheroma of vessels. 
IT. Chronic Insanity ! Membranes changed, diseased and thickened, 
and True Dementia. ] Nerve elements degenerated and atrophied. 

General atrophy of convolutions ; most marked in anterior con- 
volutions. 



DISEASES OF THE NERVOUS SYSTEM. I4I 

f Similar to preceding, but differs in distribution of lesions ; par- 
TTT PpnPrsl Paralvsi* J ticularly in neuralgia; also granular ventricular changes. 

ill. general raraiysis. j 0ften ksions in gpinal CQrd co . exist> Subarachnoid hem- 

orrhage not a frequent charge. 
IV. Syphilitic Insanity. 

In mania, chronic alcoholism, and general paralysis, pachymeningitis 
hemorrhagica is often found. Section through the thickened dura re- 
veals alternate layers of tissue and coagulated blood. 

Patients under twenty-five years of age seldom have chronic insan- 
ity; when they do, the vascular changes are less marked; in older 
patients the vessels become fatty and atheromatous. The capillaries 
show fatty change, their nuclei being first affected ; in the arteries the 
muscular coat becomes fatty. Through large tracts of brain, granular 
and amyloid bodies are found. Old inflammatory changes in the men- 
inges are quite common. The arachnoid is opaque in spots. 

The causes of insanity are very complex ; the Physical Causes are 
thus given by the same author: 



Injuries to head 



Concussion. 

Hemorrhages. 

Meningitis. 

Depressed fracture. 

Abscess. 

Tumor. 

( Gummy formations. 

Syphilis < Arteritis. 

( Meningitis, etc. 

■p. . f Malaria. 

Dyscrasise < 



Alcohol. 



Narcotic poisoning, etc. 

Delirium ebriosum. 
Delirium tremens. 



{ 

c , f Individual venery. 

bexual excess < ■** , , ,. J 

\ Masturbation. 

f Uterine difficulty. 
Peripheral irritation. . . . i Vaginismus. 

(^ Masturbation. 

The Moral Causes are misery, depression, emotions, excitement, 
remorse, fear, grief, religious fervor, excess of joy, the spirit of specu- 
lation, etc. 



142 



DIFFERENTIAL DIAGNOSIS. 



The two forms, mania and melancholia, have their general distinc- 
tions, as follows: 



MANIA. 
Ego elated and over active. 

Joy and excitement generally 
previal, sometimes comic emotions 
characterize attacks. 



Over- ideation and over-action. 
Resulting therefrom incoherence 
and delirium and violent acts; gen- 
eral restlessness. 



Insomnia. 



MELANCHOLIA. 

Ego is depressed and does not 
react normally on external world. 

Sadness and fear; religious feel- 
ings strongly developed. 

( Few mo- 
Reduced ideation. < ' , 

even abso- 
lute silence 

Immobil- 
ity relative 
or total, 
and even 
cataleptoid 
state. 



Reduced action . ^ 



Insomnia (less marked). 



Increased circulation. 
Increased calorification. 
Increased (?) assimilation 
Increased voracity. 



PHYSICAL SYMPTOMS. 

Lessened circulation. 
Lessened calorification. 
Lessened assimilation. 



The earliest symptoms of insanity are a marked change in the hab- 
its of the individual; proneness to irritability and loss of self-control; 
an alteration in the emotions; failure of memory; untidiness of dress; 
insomnia and disturbing dreams; unusual loquacity or taciturnity; de- 
fective reasoning; accepting as real various fancies and illusions; a 
furtive watchful air; groundless suspicion of those around, especially 
•of infidelity to marital vows on the part of wife or husband. In com- 
bination with these mental symptoms, the pupils are often dilated, fre- 
quently irregular and sluggish in obeying the stimulus of light; and a 
pulse hard, rapid, and variable, 100 or over, a pulse which is not equal 
in both wrists (Henry Howard). The tongue is pasty, the breath 



DISEASES OF THE NERVOUS SYSTEM. 



143 



foul, and the bowels constipated. The digestion is impaired, and the 
appetite irregular and capricious. There is encroachment of the senses 
upon each other; the sense of sight, for instance, is substituted by au- 
dition, and the patient will describe scenes with the greatest minute- 
ness of detail as occurring in the neighborhood, even to the color of 
clothing, and peculiarities of appearance which could only be learned 
by inspection, but which he knows, because he " heard the dogs bark- 
ing," or the noise of some fancied tumult. The hearing of inaudible 
voices calling opprobrious names is even popularly recognized as indi- 
cating insanity. Where no organic changes can subsequently be de- 
tected in the brain, we are forced to the conclusion that there is either 
some non-recognizable defect, or that there must be functional disor- 
der of the brain, as of other organs in the economy. 

H. C. Wood * divides complete non-periodic insanities into three 
groups on the bases of the emotional conditions, thus affording an 
easy means of recognizing clinical symptomatic groups representing 
affections of whose pathology we have no distinct knowledge : 



EMOTIONAL STATE 
Exaltation. 



Depression. 



FORM OF INSANITY. 
Acute. 
Chronic. 

Melancholia. 

Katatonia. 



Apathy from loss 
of activity, nor- 
mal or variable. 



Mania. < 
Melancholia. ■< 

Imbecility 



Mental 
Deteriorations. 



Primary 
Dementia. 

Terminal 
[_ Dementia. 



f Organic. 
Develop- 
mental. 



I Miscellaneous. 



Senile. 

Hebephrenia. 

Shock. 

Primary. 
Confusional 
Insanity. 

J Stuporous 
[_ Insanity. 

THE CLASSIFICATION OF MENTAL DISEASES. 
On the 8th of September, 1886, a conference representing various 
distinguished scientific bodies of the United States and Canada, and 
eminent alienists and publicists, was held at Saratoga, New York, for 
the purpose of co-operating with an International Committee appointed 
at Antwerp last year, under the auspices of the Belgian Society of 



* Nervous Diseases, page 471. 



1 44 DIFFERENTIAL DIAGNOSIS. 

Mental Medicine. The object was to recommend to this International 
Committee a basis for classification of mental diseases, in the hope of 
securing a uniform basis in all countries of the civilized world. The 
following plan of classification was adopted : 

1. Mania: acute, chronic, recurrent, puerperal. 

2. Melancholia: acute, chronic, recurrent, puerperal. 

3. Primary delusional insanity (monomania). 

4. Dementia: primary, secondary, senile, organic (tumors, hemor- 
rhages, etc.). 

5. General paralysis of the insane. 

6. Epilepsy. 

7. Toxic insanity (alcoholism, morphinism, et.). 

8. Congenital mental deficiency (idiocy, imbecility, cretinism). 

This classification is remarkably free from the elaborate differentia- 
tions which are now adopted by some writers. It looks like a rever- 
sion to the simplicity of a former and, it was supposed, more ignorant 
generation. The truth is that while the clinical study of insanity has 
advanced and been very prolific of a useful and instructive literature, 
our knowledge of the essential functions and pathology of the cerebral 
masses is not greatly more advanced than it was with the fathers ; and 
without more of such intimate knowledge (unbiassed by speculation 
and opinion) the very foundation for a perfectly acceptable classifica- 
tion does not exist. 






CHAPTER II. 

DISEASES OF THE RESPIRATORY APPARATUS. 

Diseases of the Larynx. — Symptoms of Laryngeal Diseases — Diag- 
nostic Table of Acute Laryngitis, Chronic Laryngitis, Syphilitic Laryn- 
gitis, Tubercular Laryngitis, Perichondritis, Benign Growths, Malig- 
?iant Growths, and Neuroses of the Larynx — Croup and Diphtheria : 
Spasmodic Croup, Lnflammatory Croup, Membranous Croup, and 
Diphtheria — Tonsillitis, Catarrhal and Parenchymatous. 

Diseases of the Lungs. — The Regions of the Chest — Normal Differ- 
ences between the two sides of the Chest — Methods of Physical Exam- 
ination — Normal Respiratory Sounds — Normal Voice Sounds — Ab- 
normal Percussion Sounds — Abnormal Respiratory Sounds — Abnor- 
mal Voice Sounds — General Rules for Diagnosis — The Forms of 
Phthisis [Catarrhal, Fibroid, Tubercular) — The Diagnosis of Incipient - 
Phthisis — Diagnosis between Incipient Phthisis and Bronchitis — Clin- 
ical History of Phthisis — Acute Phthisis — Syphilitic Phthisis — Bron- 
chitis, Acute and Chronic — Capillary Bronchitis compared with Pneu- 
monia — Pneumonia and Pleurisy — Pleurisy with Effusion and Pneu- 
monia with Consolidation compared — Diagnosis between Pneumonia;, 
and Pulmonary Apoplexy — Pulmonary Embolism — Asthma — Pneu- 
mothorax and Pneumo-hydrothorax — Emphysema, Vesicular and In- 
terlobular — Cancer of the Lung. 

In studying diseases of the respiratory apparatus, we find in addi- 
tion to the disorders of the lung proper and its serous investment, the 
pleura, that there are associated organs which likewise may be the seat, 
of disease; these are the bronchi and trachea, the larynx, pharynx,, 
and upper air passages. We commence with : 

DISEASES OF THE LARYNX. 
The general symptoms of laryngeal diseases, together with their 
causes and examples, may be arranged in the following tabular form : . 
10 (145) 



146 



DIFFERENTIAL DIAGNOSIS. 





A. — Functional, or Subjective. 


SYMPTOMS. 


ACUTE LARYNGITIS. 


CHRONIC LARYNGITIS. 


Voice. 


Hoarse, becoming apho- 
nic. 


Hoarse, uncertain, easily 
fatigued. 


Respiration. 
Cough. 


Not embarrassed prior to 
oedema; then stridor, 
dyspnoea, and even 
apnoea. 

Dry, hard, shrill, metal- 
lic, aphonic; on exud- 
ation, moist. 


Seldom embarrassed. 

Irritative, with slight ex- 
pectoration of gluti- 
nous pellets. 


Deglutition. 


Painful when oedema has 
taken place, or from 
associated pharyngeal 
inflammation. 


Rarely affected. 


Pain and Al- 
tered Sensa- 
tion. 


Sensation of tightness 
and constriction; ten- 
der to external pres- 
sure. 


Painless ; sense of fatigue 
after vocal exercise. 





B. — Physical, or Objective. 


SYMPTOMS. 


ACUTE LARYNGITIS. 


CHRONIC LARYNGITIS. 


Color. 


Intense, uniformly in- 


Partial and modified sub- 




creasing superficial hy- 
peraemia ; translucent 
on event of oedema. 


mucous hyperaemia. 


Form and Tex- 


Thickening and stenosis 


Occasionally slight ero- 


ture. 


from oedema, loss of 


sion, never ulceration, 




tissue rare, except in 


thickening or narrow- 




phlegmonous form. 


ing. 


Position. 


Unaltered. 


Unaltered. 



C. — Miscellaneous. 



SYMPTOMS. 



External. 



ACUTE LARYNGITIS. 



Pharynx usually syn- 
chronously implicated. 



CHRONIC LARYNGITIS. 



Pharynx usually syn- 
chronously implicated. 



DISEASES OF THE RESPIRATORY APPARATUS. 



147 



SYPHILITIC LARYNGITIS. 

Secondary. Hoarse. 

Tertiary. Characteristicly rau- 
cous; seldom aphonic. 

Secondary . Unchanged. 

Tertiary. Increasing embarrass- 
ment according to stenosis. 

Secondary. Slight hacking. 

Tertiary. Infrequent, with but 
slight expectoration, unless 
peri-chondritis supervene. 

{Secondary. Varies with deposit 
on epiglottis or arytenoids. 
Tertiary. Often difficult; very 
rarely painful. 
Characteristic absence of pain 
except when cartilages are 
attacked. 

r Secondary. Mottled, more or 
less symmetrical hyperemia. 

Tertiary. Hyperaemia of portion 
attacked prior to ulceration ; 
with infiltrated appearance. 

Secondary. Occasional super- 
ficial ulceration at vocal pro- 
cess; slight general submuc- 
ous infiltration. 

Tertiary. Deep, circumscribed 
destructive ulcers, of yellow- 
ish color, followed by cicatri- 
cial narrowing, occasionally 
paralysis and new formations. 

r Secondary. Unaltered. 
Tertiary. Deformity from in- 
trinsic cicatrices and pharyn- 
geal outgrowths. 

r Secondary. Pharynx and skin 
generally recently implicated. 
Tertiary. Seldom synchronous 
implication, but usually scars 
of previous similar pharyngeal 
ulceration, possibly adhesion. 



TUBERCULAR LARYNGITIS. 



Sometimes aphonic in earlier 
stages; completely lost in ad- 
vanced disease. 

Early hurried ; greatly embarrassed 
with advance of disease. 

Greatly influenced by amonnt of 

lung disease; painful. 
Expectoration variable; generally 

frothy. 
Extremely difficult and painful, 

from early period to termination. 



Pain only experienced in functional 
acts 

Anaemia followed by opaque gray- 
ish color; margins of ulcers hy- 
peremia 



Solid submucous thickening of epi- 
glottis and aryepiglottic folds, 
elevation and ulceration of race- 
mose glands giving worm-eaten 
ulcers, which commingle and at- 
tack deeper tissues. 



No displacement; tendency for 
thickened parts to transgress 
boundaries of pharynx. 

Lungs either primarily, synchro- 
nously, or subsequently involved. 
Generally anaemia, rarely ulcera- 
tion of pharynx. General emaci- 
ation. 



143 



DIFFERENTIAL DIAGNOSIS. 



A. — Functional, or Subjective. 



SYMPTOMS. 



Voice. 



Respiration. 



Cough. 



Deglutition. 



Pain and Al- 
tered Sensa- 
tion. 



perichondritis. 



Painful, easily fatigued, 
but not necessarily im- 
paired. 



Variable according 
cartilage attacked. 



to 



Generally early spasmod- 
ic; with caries charac- 
teristic. 

Purulent expectoration, 
unless abscess is en- 
cysted. 

Varying from dysphagia 
to aphagia, according 
to pressure on gullet. 



Pain variable with cause; 
most severe in gouty 
form, but not then con- 
stant. 

B. — Physical, or Objective 



BENIGN GROWTHS. 

Very variable, from 
slight hoarseness to 
complete aphonia, even 
in the same case. 

Seriously embarrassed in 
one-sixth of cases ; de- 
pends on situation. 

Generally limited to effort 
to dislodge foreign 
body; may be expec- 
toration of atoms of 
growth. 

Only impaired in rare 
cases, in which epiglot- 
tis or aryepiglottic fold 
is involved. 



Characteristically absent. 



Color. I Hyperemia generally 

limited to portion at- 
tacked, sometimes ex- 
tending to contiguous 
vocal cord. 

Form and Tex- Ulceration often absent, 
ture. substituted by en- 

cysted abscess, causing 
narrowing, compres- 
sion and paralysis. 

Position. May be considerable al- 

teration of supra- and 
infra-glottic space. 

C. — Miscellaneous. 



Variable with nature of 
neoplasm; slightly in- 
creased vascularity of 
mucosa generally. 

Varies with situation, size 
and nature of growth, 
never ulceration. May 
cause narrowing and 
paralysis. 

Position of normal parts 
seldom changed. 



External. I Occasional constitutional I Nil. 

manifestations. 



DISEASES OF THE RESPIRATORY APPARATUS. 



149 



MALIGNANT GROWTHS. 



Impaired by mechanical causes 
when invaded from pharynx; may 
be early lost in primary disease. 

Early quickened on exertion; 
later paroxysmal dyspncea from 
stenosis or compression. 

Not necessarily present ; expec- 
toration scanty ; occasionally 
blood and portions of neoplasm. 

Always difficult and painful ; 
often the earliest symptom. 

Ever present and severe, extend- 
ing upward to the ears, and to 
sympathetic glandular enlarge- 
ments. 

Increasing localized vascularity 
tending to lividity in any part ex- 
cept vocal cords or ventricles, 
when neoplasm is whitish-gray 
or pale rose. 

May cause compression, narrow- 
ing and paralysis before ulcera- 
tion, which is always accompanied 
by thickening. Extensive indolent 
gray, greenish, or almost black 
ulcers. 

Early displacement, especially 
when invading from pharynx, and 
when neighboring glands enlarged. 

Glandular infiltration, but com- 
plete immunity of other organs 
of body from similar disease both 
prior and subsequent to appear- 
ance in laryngo-pharynx. General 
emaciation. 



NEUROSES. 



Lost in bilateral paralysis of 
adductors ; impaired in other pa- 
ralyses; not necessarily in spasm. 

Only embarrassed in paralyses 
of adductors and in spasmodic af- 
fections. 

Paroxysmal, when recurrent, is 
implicated and in spasmodic affec- 
tions. 

But slightly impaired or unaf- 
fected. 

Only experienced when sensory 
system affected. Diminished sen- 
sation in motor paralyses and in 
anaesthesia. 

In paralysis of abductors, oc- 
casional vascularity of affected 
vocal cords. 



Form of glottis varying with 
nature of paralysis, without ex- 
trinsic thickening. 



Paralyzed cord not displaced, 
but often fixed in one position. 

Sympathetic functional disturb- 
ances in other organs, or organic 
disease of cardiac or lymphatic 
system, or associated cerebral 
disease or chronic toxaemia. 



i 5 o 



DIFFERENTIAL DIAGNOSIS. 



SYMPTOMS OF LARYNGEAL DISEASES. 



SYMPTOMS. 


CAUSES. 


EXAMPLES OF DISEASE. 


Dysphonia. 


Alteration in the vocal 


Acute and chronic laryn- 




cords from thicken- 


gitis. 


> 


ing, ulceration, dimin- 


Laryngeal phthisis. 




ished tension, morbid 


Papillomata, etc. 




growths, etc. 




Aphonia. 


Non-approximation of 


Cicatrization. 




the vocal cords, either 


Swelling of arytenoid car- 




mechanical or due to 


tilages. 




paralysis of some of 


Tumors. 




the muscles attached 


Pressure on recurrent la- 




to them. 


ryngeal nerves, etc. 


Dyspnoea. 


Narrowing of the orifice 


Paralysis of muscles 




of the glottis. 


opening glottis. 

Laryngismus stridulus. 

(Edema, growths and 
cicatrices contracting 
rima glottidis, and 
pressure external to 
larynx. 


Stridor. 


Always accompanied by 
dyspncea, and pro- 
duced by the same 
causes. 


As in dyspncea. 


Cough. 


Irritation of the laryn- 


In most laryngeal dis- 




geal mucous mem- 


eases it is of a peculiar 




brane, or the nerves of 


shrill, brazen charac- 




the larynx. 


ter. 



Laryngitis has been divided by some writers into the following 



forms : 

CEdematous laryngitis. 
Catarrhal laryngitis. 
Erysipelatous laryngitis. 
Croupous laryngitis. 



Diphtheritic laryngitis. 
Syphilitic laryngitis. 
Tubercular laryngitis. 
Exanthematous laryngitis. 



TRAUMATIC LARYNGITIS. 
Among authors who have paid especial attention to this subject, 
there are few that stand higher than Mr. Lennox Browne, of Lon- 



DISEASES OF THE RESPIRATORY APPARATUS. 15 I 

don, who in his work on the Diseases of the Larynx gives the diag- 
nostic table presented in the preceding pages. 

The chronic laryngitis of syphilis cannot with certainty be distin- 
guished from the other forms of chronic laryngitis without inquiry in- 
to the history of the case; although a probable diagnosis maybe made 
where treatment by anti-syphilitic remedies is successful. 

In tertiary syphilis there is deep and extensive ulceration, not neces- 
sarily preceded by thickening; the epiglottis is attacked early, the ul- 
ceration is often followed by cicatrization and contraction, causing 
stenosis of the larynx. 

In the study of laryngeal diseases the use of the laryngoscope is 
indispensable to correctness of diagnosis. We take it for granted 
that the practitioner is conversant with this instrument, and the proper 
methods of employing it. It reveals the physical or objective local 
symptoms, which are of much more value than the subjective ones 
derived from the patient's statements. 

CROUP AND DIPHTHERIA. 
The general sign common to this class of diseases is a laryngeal 
stridor ; they are divided into those where there is a formation of false 
membrane and where there is not. 
Without false membrane. 

Spasmodic croup or laryngismus stridulus. 
Inflammatory croup, simple catarrhal laryngitis. 
With false membrane. 

True croup or membranous croup. 
Diphtheria. 
The diagnosis between spasmodic and inflammatory croup is as. 
follows : 



SPASMODIC CROUP. 

Onset sudden, usually at night, 
with few or no prodromal symp- 
toms. 

Difficulty of swallowing absent 
or temporary. 

Febrile symptoms absent, or 
much less marked. 



INFLAMMATORY CROUP. 

Onset gradual, with sore throat,, 
tickling, tenderness of larynx andi 
catarrh. 

Increasing diffiulty in swallow- 
ing. 

Flushed face, hot, dry skin, highi 
temperature (105 ); frequent pulse.. 



152 



DIFFERENTIAL DIAGNOSIS. 



SPASMODIC CROUP. 
Larynx little affected. 

Intermission complete, or nearly 
so, between the croupous attacks. 

Very rarely fatal. 



INFLAMMATORY CROUP. 

Mucous membrane ot larynx red 
and swollen, sometimes cedematous. 

Remission but slight; local symp- 
toms and pyrexia continue. 

In early life a dangerous disease. 



Very considerable differences of opinion are entertained as to the 
formidable and frequent disease diphtheria. Some maintain its identity 
with membranous croup, others with scarlatina, while others believe it 
to be a malady distinct in origin, course, result and treatment from 
them both. The last mentioned opinion appears to have the most ad- 
herents, and the most facts on its side. The differences between the 
diseases are fully set forth in the table subjoined: 



MEMBRANOUS CROUP. 

It is a local complaint, rarely if 
ever occurring after puberty. A 
rare disease. 



not contagious. Type 
cough, ca- 



It is 
sthenic. 

Commences with a 
tarrh and hoarseness; little or no l 
sore throat and difficulty of swal- 
lowing. Cough shrill, metallic; 
breathing stridulous from the out- 
set. 

The membranous affection be- 
gins in the larynx and extends to 
the throat. 

Fauces injected but rarely swol- 
len, and generally without exuda- 
" tion. 

Exudation never cutaneous. 

No swelling of the submaxillary 
■glands. 

Epistaxis and albuminuria ab- 
sent 



DIPHTHERIA. 

Is a general disease, common to 
all ages. A disease of frequent 
occurrence, often epidemic or en- 
demic. 

It is decidedly contagious. Type 
asthenic. 

Commences with a chill, sore 
throat, difficulty- of swallowing; but 
neither hoarseness nor cough at 
the outset. Stridulous breathing 
a late symptom. 

The membranous affection be- 
gins in the throat and thence ex- 
tends to the Larynx (Da Costa). 

Fauces injected, swollen and 
presenting exudation. 

Exudation often cutaneous. 
Submaxillar}- glands swollen. 

Epistaxis and albuminuria fre- 
quent. 




DISEASES OF THE RESPIRATORY APPARATUS. 



153 



MEMBRANOUS CROUP. 

Symptoms local; often no pros- 
tration of the general strength. 

Relief follows the use of emetics, 
local counter-irritants, expectorants 
and depressants. 

Is never followed by paralysis. 



Less often fatal. Death from ap- 
ncea. Blood not changed. Spleen 
not affected. , 



DIPHTHERIA. 

Considerable, often extreme 
prostration. 

Demands a stimulating and sus- 
taining treatment. 



Subsequent paralysis not infre- 
quent. 

Frequently fatal. Death usually 
by asthenia. Blood after death 
usually fluid and dirty brown. 
Spleen enlarged and softened (J. 
W. Howard). 

With regard to pathology, a recent authority states that fibrinous 
and diphtheritic exudations are usually considered to be characteristic 
of croup and diphtheria, and yet diphtheritic inflammation is no more 
to be confounded with the disease diphtheria than is fibrinous inflam- 
mation with the disease croup (Fitz.*) Diphtheria may exist without 
the formation of false membrane, or various exudations" may be pres- 
ent ; mucous, fibrinous or diphtheritic. On the other hand, diphthe- 
ritic deposit occurs in other diseases than diphtheria, as in diphtheritic 
conjunctivitis, and diphtheritic inflammations of wounds and of vario- 
lous eruptions. The characteristics of a diphtheritic inflammation are 
the presence within the tissues of a clotted exudation, associated with 
defined swelling and local necrosis. With leucocytes, interlacing 
fibres and granular material, micro-organisms are detected by the mi- 
croscope (micrococci diphtheriae). 

TONSILLITIS. 
Inflammation of the tonsils assumes two forms, in one of which, the 
catarrhal form, the inflammation extends to the secreting tissues and 
lining membrane of the crypts, and in the other to the parenchyma- 
tous structure of the gland. These two forms differ widely in cause, 
in symptoms, in treatment and result. Their diagnostic symptoms, 
as tabulated by Mr. Arthur Treherne NoRTON,t are as follows : 

* Vol. 1, Pepper's System of Medicine, page 50, Phila., 1885. 
f British Medical Journal, Jan., 1874. 



154 DIFFERENTIAL DIAGNOSIS. 



FOLLICULAR TONSILLITIS. 

Is a mucous inflammation of 
three or four days' duration. 

Caused by exposure to draught, 
damp, cold, etc. 

Prostration and often profuse 
perspiration. Pulse small and 
quick. Never runs on to abscess. 

Both tonsils affected. 

Lacunae filled with masses of 
morbid secretion, may even resem- 
ble ulcers. 

No oedema around. 



PARENCHYMATOUS TONSILLITIS. 

Is a fibrous inflammation of from 
two to four weeks' duration. 

Often caused by neighboring in- 
flammation, cutting wisdom teeth. 

High fever, with hot, dry skin. 
Pulse strong and hard. Commonly 
forms an abscess. 

Rarely both affected. 

Often covered with lymph, but 
no collection of secretion in lacu- 
nae. 

Extensive oedema. 



DISEASES OF THE LUNGS. 

In passing from the consideration of the disorders of the upper air- 
passages to the diseases of the lungs, it is thought advisable to discuss 
somewhat in detail the several methods of examination of the patient, 
and to consider systematically the various objective phenomena pre- 
sented by them as introductory to the study of their alterations, which 
are characteristic of certain diseases. Palpation, mensuration, auscul- 
tation and percussion, therefore, furnish evidence of great clinical im- 
portance, which may be considered collectively under the head of 
physical diagnosis. 

The study of Physical Diagnosis necessarily commences with a cor- 
rect appreciation of the location of organs, their functions and physical 
characters in health; to which must follow a clear understanding of the 
specific and peculiar alterations which each of these elements under- 
goes when it becomes a factor in disease. To acquire this, we give on 
the following pages tabular arrangements of the following subjects : 

I. The Regions of the Chest, their Contents and Normal Signs. 
II. The Normal Differences between the two Sides of the Chest. III. 
Methods of Physical Examination. IV. Normal Respiratory Sounds. 
V. Normal Voice Sounds. VI. Abnormal Resonance on Percussion, 
and its Causes. VII. Abnormal Intensity, Rhythm, and Quality of 
Respiratory Sounds. VIII. Abnormal (dry) Respiratory Sounds. 
IX. Abnormal (moist) Respiratory Sounds. X. Abnormal (amphoric) 
Respiratory Sounds. XI. Abnormal Voice Sounds. 



DISEASES OF THE RESPIRATORY APPARATUS. 



55 



I. THE REGIONS OF THE CHEST. 







resonance on 




REGION. 


contents. 


percussion in 


auscultation in 






health. 


HEALTH. 


i. Cervical. 


Larynx and tra- 




Tracheal breathing and 




chea. 




voice. 


2. Supra-clavicular. 


Apex of lung. 


Clear. 


Very pure vesicular 
murmur (scarcely au- 
dible) ; voice scarcely 
audible. 


3. Clavicular. 


Clavicles and ves- 


Clear. 


Pure vesicular murmur 




icular structure of 




and scarcely audible 




lung. 




voice, except at the 
sternal end; where 
are bronchial breath- 
ing and bronchophony. 


4. Subclavian. 


Vesicular structure 


Clear. Rather 


Pure vesicular murmur 




of lung. 


higher pitched 


and scarcely audible 






percussion note 


voice. Heart sounds 






on right side than 


on left side below. 






on the left. 




5. Mammary. 


Vesicular structure 


Clear on right side. 


Pure vesicular murmur 




of lung. Heart 


Dull on left in 


above. Heart sounds 




on left side. 


greater part of re- 


below on left side, and 






gion. 


feeble vesicular mur- 
mur on right. Voice 
scarcely audible. 


6. Infra-mammary. 


Anterior portion of 


Generally tympan- 


Distinct vesicular mur- 




base of lung. 


itic on left side; 


mur. Voice scarcely 




Stomach below, 


dull on right. 


audible. 




on left side, liver 








on right. 






7. Superior sternal. 


Division of tra- 


Clear. 


Bronchial breathing and 




chea, aorta, and 




bronchophony. 




great vessels. 






8. Inferior sternal. 


Anterior medias- 


Clear above; tym- 


Pure vesicular murmur 




tinum above. 


panitic below. 


above, becoming fee- 




Stomach below. 




ble below. Voice 
scarcely audible. 


9. Axillary. 


Vesicular structure 


Clear. 


Pure vesicular murmur. 




of lung. 




Voice scarcely audible. 


10. Lateral. 


Vesicular structure 


Clear above; dull 


Pure vesicular murmur. 




of lung. 


below on right 
side. 


Voice scarcely audible. 


11. Supra-scapular. 


Apex of lung. 


Clear. 


Pure vesicular murmur. 
Voice scarcely audible. 


12. Scapular. 


Vesicular structure 


Rather less clear. 


Pure vesicular murmur. 




of lung. 




Voice scarcely audible. 


T3. Inter-scapular. 


Roots of lung and 


Clear. 


Bronchial breathing and 




large bronchi. 




bronchophony. 


14. Infra-scapular. 


Base of lung. 


Clear. 


Very pure vesicular 
murmur. Voice scarce- 
ly audible. 



i 5 6 



DIFFERENTIAL DIAGNOSIS. 



II. NORMAL DIFFERENCES BETWEEN THE TWO SIDES OF THE 
CHEST. (A. H. Smith.) 



Percussion Resonance. 
Vocal Resonance. 

Bronchial Whisper. 
Inspiratory Sound. 



Expiration. 



RIGHT SIDE. 



Decidedly greater on the right 
side. 

More intense than on the left, 
and a little lower in pitch. 



Frequently prolonged in 
healthy individuals on this 
side. 



LEFT SIDE. 



A little more intense than on 
the right side. 



A little lower on this side, more 
vesicular in quality, and lower 
in pitch. 



III. METHODS OF PHYSICAL EXAMINATION. 



METHODS OF EXAMI- 
NATION. 

i. Inspection. 



2. Palpation. 

{Application of the 
hands.) 



Mensuration. 
(a) Of Size, 
(d) Of Movement. 



4. Percussion. 



instruments used. 



Form, symmetry and capacity 
of the chest. 

Local bulging, depression or 
retraction. 

Condition of intercostal spaces. 

Character and frequency of res- 
piratory movements. 

Comparative size and degree 
of movement of the two 
sides. 

Position and extent of impulse 
of heart. 

Comparative movement of the 

two sides. 
Vibration communicated to 

the chest wall by the voice 
» (vocal vibration or vocal 

fremitus.) 
Force of the heart's impulse. 
Occasionally certain morbid 

phenomena, as pleural and 

pericardial friction, valvular 

thrill. 

Comparative size of the two Graduated tape. 

sides of the chest. | Cyrtometer. 

Actual and comparative move- j Dr. Sibson's stethometer. 

ment of the chest in respira- Dr. Quain's stethometer. 

tion. Dr. Edward's chest calipers. 

Dr. Hutchinson's spirometer. 

of resonance in vari- \ Plessor — A hammer tipped with 



Degree 
ous parts of the chest. 



india rubber. 



DISEASES OF THE RESPIRATORY APPARATUS. 1 57 

III.— METHODS OF PHYSICAL EXAMINATION— {Continued.) 



METHODS OF EXAMI- 
NATION. 



5. Auscultation. 



6. Succussion. 



REVEALS. 



Extent of cardiac dulness. 



Character of respiratory mur" 
mur. 
Abnormal respiratory sounds. 
Heart sounds. 
Abnormal cardiac sounds. 

Presence of air and fluid in 
pleural cavity. 



INSTRUMENTS USED. 



The first and second fingers of 
the right hand will be found to be 
the best plessor. 
Pleximeter — A thin plate of ivory 
or bone. 

The forefinger of the left hand 
will be found to be the best plexi- 
meter. 

Stethoscope — Made of wood, metal, 
or vulcanite. 

Dr. Scott Alison's bin-aural stetho- 
scope. 



Percussion may be — Immediate — Where the chest is struck directly, 
without the interposition of any pleximeter. 

(2) Mediate. — Where, between the 'chest and the substance with 
which the stroke is made, an instrument termed a pleximeter is inter- 
posed. This may be either a thin plate of ivory or bone, or, still bet- 
ter, the first and second fingers of the left hand. 

Auscultation may be — Immediate. — Where the ear is applied di- 
rectly to the walls of the chest. 

(2) Mediate. — Where the stethoscope is interposed between the ear 
and the walls of the chest. 

IV. NORMAL RESPIRATORY SOUNDS. 



Vesicular Breathing. 



Puerile Breathing. 



SITUATION WHERE HEARD. 



All over the chest except the upper part 
of the sternum and the space between 
the scapulae, the respiratory sound be- 
ing louder, and three or four times 
longer than the expiratory. 

Is the loud vesicular breathing of chil- 
dren audible over the same parts of the 
chest as the ordinary vesicular breath- 



I58 DIFFERENTIAL DIAGNOSIS. 

IV. NORMAL RESPIRATORY SOUNDS.— {Continued.) 



SOUND. 



Bronchial Breathing. 



Tracheal "] 

or V Breathing. 
Laryngeal J 



SITUATION WHERE HEARD. 



Upper part of the sternum and the space 
between the scapulae in many healthy- 
persons. 

Over the trachea and larynx. 



V. NORMAL VOICE SOUNDS. 



SOUND. 



Ordinary Vocal Reso- 
nance. 



Natural Bronchophony. 



Laeyngophony and Tra- 
chophony. 



SITUATION AND CHARACTER. 



Is the voice-sound heard over the pulmo- 
nary regions where vesicular murmur 
is audible. A muffled, diffused sound ; 
the articulation of the voice is not ap- 
preciable. 

Heard over the upper part of the ster- 
num, and between the scapulae in a cer- 
tain number of healthy persons. A more 
distinct and concentrated sound than the 
last variety. 

Voice-sounds heard over the larynx and 
trachea. Voice transmitted imperfectly 
articulated to the ear of the observer, 
with so much loudness and concentra- 
tion as even to be painful. 



DISEASES OF THE RESPIRATORY APPARATUS. 
VI. ABNORMAL RESONANCE ON PERCUSSION. 



159 



RESONANCE. 



Diminished 



in 



various degrees 

or altogether 

Absent. 



Increased. 



Tympanitic. 
Amphoric. 



Box-like. 
Cracked-pot 
Sound. 



CAUSE. 



Deficiency of air, or ab- 
normal deposit, in the 
lung beneath the part 
percussed; or solid or 
liquid matter between 
the walls of the chests 
and the lung contain- 
ing air ; or extreme 
distention of the chest 
with air. 



Air increased in quan- 
> tity, or air in pleural < 
cavity. 

A large cavity (or con- 
ditions resembling it) 
with very tense walls, 
containing air. 

Air expelled from cavity 
by sudden pressure. 



EXAMPLES OF DISEASE. 



Pneumonia, first stage. 

Phthisis; contracted 
lung, with thickened 
pleura. 

CEdema and congestion 
of lung. 

Tumors. 

Collapse of lung. 

Pneumonia, second and 
third stages. 

Intra-thoracic tumors 
and aneurisms. 

Effusions into pleural 
cavity, or its extreme 
distention by air. 

Emphysema. 

Tubercular cavity, hav- 
ing thin walls, and sit- 
uated near the surface. 

Pneumothorax. 

Extreme emphysema. 

Upper part of lung com- 
pressed by fluid below. 

Hydro-pneumothorax. 

Cavities. 

Cavity of considerable 
size, with large bron- 
chus opening into it, 
(mouth of patient being 
open during percus- 
sion.) 



i6o 



DIFFERENTIAL DIAGNOSIS. 



VII. ABNORMAL INTENSITY, RHYTHM, AND QUALITY OF 
RESPIRATORY SOUNDS. 









condition of 


EXAMPLES OF 




SOUNDS. 


chief causes. 


ORGANS. 


DISEASE. 




Feeble Breathing. 


Air entering the 


Lung partially 


Incipient 






air cells in di- 


solidified either 


phthisis. 






minished quan- 


by increase of 


Bronchitis. 






tity and force. 


solid or fluid 
within it, or by 
pressure from 
without; dilata- 


Pneumonia, first 

stage. 
Tumors. 
Pleurisy. 


>> 






tion of the air- 


Emphysema. 


'w 






vesicles; in 


Pleurodynia. 








some cases 








lungs not affec- 




»-• 






ted. 




.S - 


Extinct Breathing. 


The presence of 


Lung solidified 


Pleuritic e ff u- 


in 

O 




a non-conduct- 


by pressure up- 


sion. 




ing medium be- 


on its surface ; 


Pneumothorax. 






tween the lung 


plug of mucus, 


Plastic bronch- 


A 




and the chest- 


fibrinous exu- 


itis. 


O 




wall, or some 


dation or for- 


Tumors. 


t-5 




impediment to 


eign body in 


Foreign body in 






the entrance of 


the bronchi, or 


bronchus. 






air into the 


tumor com- 








bronchi. 


pressing the 
bronchi. 






Puerile, or~| 


Air entering the 


Healthy, but ex- 


Disease of oppo- 




Supplemen- I Breathing. 


air-cells with 


aggerated i n 


site lung or of 




tary. J 


increased rap- 


function. 


other parts of 






idity and force. 




the same lung. 
Met with as a 
normal condi- 
tion in child- 
hood. 




' 


Re spiratory 


Varies with the 


Pleurodynia. 






movements re- 


disease causing 


Pleurisy. 




Inter-] 


strained by 


it. 


Debility, with 


RUPTED, | 


pain, or mental 




palpitation. 


>» 


Jerking, f- Breathing. 
Cogged- ] 


emotion, or 




Hysteria. 


C 

w 
u 


some tempo- 




Incipient phth- 


wheel J 


rary local ob- 




isis. 




struction of the 




Spasmodic 




air-tubes. 




asthma. 




Prolonged Expiration. 


Loss of elasticity 


Thinning of the 


Emphysema. 


rt 




in the lung tis- 


walls of the air 




O 




sue. 


vesicles, with 
dilatation and 










destruction o f 
the alv eo lar 
septa. 





DISEASES OF THE RESPIRATORY APPARATUS. 



161 



ABNORMAL INTENSITY, RHYTHM AND QUALITY OF RESPIRATORY 

SOUNDS— ( Continued.). 









CONDITION OF 


EXAMPLES OF 




SOUNDS. 


CHIEF CAUSES. 














ORGANS. 


DISEASE. 










Lung not solidi- 


Generally con- 










fied (soft sound). 


sistent with 
health and 
supplement- 




' EXAGGER- 1 








ary. 
Heard in cases 




ated, I Breathing. 


Increased friction 






of uraemia and 


£> 


Coarse J 


in the air-cells 






other blood 






and smaller bron- 


" 




poisoned dis- 


"3 

3 




chial tubes. 






eases, and in 


o> 










hysteria and 


.5 










nervous dis- 


03 










eases. 










Lung solidified or 


Incipient 


C 








bronchial tubes 


phthisis. 


J3 








obstructed (harsh 




O 








sound) . 




>-* 


Blowing, ] 


Friction of air in 


Condensation of the 


Phthisis. 


i-4 


Tubular, 


the bronchial 


lung between the 


Pneumonia. 




or Bron- I Breathing. 


tubes, or in cav- 


chest wall and the 


Tumors. 




chial Ca- 1 


ities of the lung. 


larger bronchi or 


Tubercular and 




vernous J 




cavities. 


other cavities. 




_ Amphoric Breathing. 


Air passing into a 


Cavities with dense 


Pneumothorax. 






large cavity with 


walls. 


Dilated bron- 






dense walls. 




chi. 
Large cavities. 


VIII. ABNORMAL DRY RESPIRATORY SOUNDS. 






• • 




EXAMPLES OF 




SOUND. 


SITUATION. 


CAUSE. 


DISEASE. 


Sib i 


LUS. 


Smaller bronchial 


Vibration of thick mucus attached 


Bronchitis. 






tubes. 


to the wall of the tube, or contrac- 
tion of the tube, due either to swel- 
ling or spasm ; not easily removed 
by cough. 


Emphysema. . 
Asthma.. 


Rhc 


)NCHUS. 


Larger bronchial 
tubes. 


Vibration of thick mucus in tubes ; 
generally easily removed by cough. 


Bronchitis. 



CLICKING OR CRACKLING. 



Dry Crackling. 



Humid Crackling. 
Pleural Friction 
Sound. 



Creaking Sound. 
ii 



Smaller Bronchi. 

Smaller bronchi. 
► Layers of pleura. 



Separation of the ad- 
herent walls of the 
bronchi — the dry 
tending to pass into 
the moist variety. 
Movement of opposed 
surfaces of pleura 
roughened by the de- 
posit of lymph or tu- 
bercle. 



Incipient phthisis. 



Softening tubercle. 

Pleurisy before effu- 
sion has commenced, 
or after absorption of 
the fluid. 



1 62 



DIFFERENTIAL DIAGNOSIS. 



IX. ABNORMAL MOIST RESPIRATORY SOUNDS. 



SOUND. 


SITUATION. 


CAUSE. 


EXAMPLES OF 
DISEASE. 


Crepitant Rale. 


Air-vesicles. 


Opening up of collapsed 


Pneumonia in first 


[Fine or pneumonic 




air-cells, or separation 


stage. 


crepitation). 




of their adherent walls. 


Qidema of lungs. 
Collapse. 
Capillary bronchi- 


SUBCREPITANT RALE. 


Smaller bronchial 


Bursting of air-bubbles 


(Medium crepita- 


tubes. 


in fluid. 


tis. 


tion). 






Phthisical bronchi- 
tis. 
Resolution of pneu- 












. 


monia. 








OZdema of lung. 








Pulmonary apo- 








plexy. 


Mucous Rale. 


Larger tubes and 


Bursting of air- bubbles 


Phthisis. 


( Large crepitation.} 


small or moderate- 


in fluid. 


Bronchitis. 




sized cavities. 




Haemoptysis. 


Gurgling or Cav- 


Large cavities (or 


Bursting of air-bubbles 


Phthisis (3d stage). 


ernous Rale. 


number of small 
cavities). 


in fluid. 


Bronchiectasis. 


Churning Sound. 


Lung in a state of 




Abscess of lungs. 




disorganization. 




Gangrene of lung. 



X. ABNORMAL AMPHORIC SOUND. 



SOUND. 



Splash on Succus- 
sion. 



Bell Sound. 



Amphoric Echo and 
Metallic Tink- 
ling. 



situation. 



Cavity of pleura or 
large cavity. 

Cavity of pleura. 



Cavities. 



CAUSE. 



Sudden disturbance of 
air and fluid existing 
together. 

Auscultation of an air- 
containing cavity while 
an assistant uses two 
coins, one as a ham- 
mer, the other as a 
pleximeter. 

Vibration of air in large 
cavities with tense 
walls. The former 
may be produced by 
rales and rhonchi in 
the chest, by the voice, 
and by the act of 
coughing ; the latter 
requires, in addition, a 
little fluid at the bot- 
tom of the cavity, set 
in vibration by a mo- 
mentary impulse, such 
as the fall of a drop of 
fluid, and is essentially 
the echo of a bubble. 



EXAMPLES OF 
DISEASE. 

Pneumotho rax 

with effusion. 
Very large cavity. 
Pneumothorax. 



Phthisis with very 
large cavities. 

Pneumotho rax 
with effusion. 



DISEASES OF THE RESPIRATORY APPARATUS. 
XI. ABNORMAL VOICE SOUNDS. 



163 



SOUND OF VOICE. 



Feeble or absent 
Vocal Resonance. 



Exaggerated Vocal 
Resonance. 



Bronchophony. 



Pectoriloquy. 



Amphoric Reso- 
nance or Echo. 



CEgophony. 



character of 

SOUND. 



The obscure hum- 
ming of-buzzing 
noise heard over the 
normal chest either 
very feeble or alto- 
gether absent. 

Voice sounds unal- 
tered in quality or 
distribution, but 
louder and of great- 
er intensity than 
natural. 



Voice - sounds heard 
louder, clearer, and 
more vibratory than 
natural, but unat- 
tended with articu- 
lation or tactile sen- 
sation to the ear. 



Voice - sounds dis- 
tinctly articulated 
and concentrated 
and as if spoken in 
to the end of the 
stethoscope. 

A ringing metallic 
sound resembling 
that produced by 
speaking into an 
empty jar. 

A tremulous vibratory 
sound resembling 
the bleating of a 
goat, or the nasal 
Punchinello voice. 



CAUSE. 



Primary bronchus ob- 
structed; conducting 
medium in pleura or 
rarefied condition of 
lung. 

Increased resound- 
ing or conducting 
power due to con 
solidation of the 
lung, or to the for- 
mation of abnormal 
spaces. 

Much increased re 
sounding or con- 
ducting power. 



Large abnormal cav- 
ity with dense walls. 



The voice reverber- 
ating in a large cav- 
ity with a small ap- 
erture. 

A thin layer of fluid 
in the pleural cavity, 
with condensed lung 
behind. 



examples of 

DISEASE. 



Tumors compressing, 
or foreign body in 
bronchus. 

Pneumothorax. 

Pleuritic effusion. 

Emphysema. 

Incipient phthisis. 
Dilatation of bronchi. 



Cavities due to phthi- 
sis or dilatation of 
the bronchi. 

Consolidation of the 
lung resulting from 
collapse, h ae m o r- 
rhaeic infarctions, 
pneumonia, phthi- 
sis, cancer, etc. 



ted 



Phthisis, d i 1 
bronchi, etc. 



Phthisis. 
Pneumothorax, 



Pleurisy with effu- 
sion. 



The quality and pitch of the vocal resonance varies greatly in differ- 
ent individuals, and as a diagnostic aid is almost useless in women. 
Whispering, sometimes, will give more satisfactory results than the 
loud " one, two, three," that is so constantly heard in our clinical am- 
phitheatres. The use of a small reed whistle, such as is found in chil- 



164 DIFFERENTIAL DIAGNOSIS. 

dren's rubber toys, will often give more uniform effects for comparison 
than the voice. 

GENERAL RULES FOR THE DIAGNOSIS OF DISEASES 
OF THE RESPIRATORY SYSTEM. 
The late Dr. John Hughes Bennett laid down the following prac- 
tical rules : 

1. A friction murmur heard over the pulmonary organs indicates a 
pleuritic exudation. 

2. Moist or dry rales, without dulness on percussion, or increased 
vocal resonance, indicate bronchitis. 

3. Dry rales accompanying expiration, with unusual resonance on 
percussion, indicate emphysema. 

4. A moist rale at the base of the lung, with dulness on percussion, 
and increased vocal resonance, indicates pneumonia. 

5. Harshness of the respiratory murmur, prolonged expiration and 
increased vocal resonance confined to the apex of the lung, indicates 
incipient phthisis. 

6. Moist rales with dulness on percussion, and increased vocal reso- 
nance at the apex of the lung, indicate either advanced phthisis or 
pneumonia, generally phthisis. 

7. Circumscribed bronchophony or pectoriloquy, with cavernous 
dry or moist rales, indicates a cavity. This may be one dependent on 
tubercular ulceration, a gangrenous abscess, or a bronchial dilatation. 
The first is generally at the apex, and the last two about the centre of 
the lung. 

8. Total absence of respiration indicates a collection of fluid or of 
air in the pleural cavity. In the former case there is diffused dulness, 
and in the latter diffused tympany on percussion. 

9. Marked permanent dulness, with increased vocal resonance and 
diminution or absence of respiration, may depend on a chronic plastic 
pleurisy, a thoracic aneurism, or a cancerous tumor of the lung. 

THE FORMS OF PHTHISIS. 
Most systematic writers, both in the United States and Europe, are 
agreed in recognizing three principal clinical varieties of phthisis. * It 
is of import, both to the prognosis and therapeutics of the case, to dis- 



DISEASES OF THE RESPIRATORY APPARATUS. 1 65 

tinguish these aspects of the disease; and although in many cases the 
type is by no means prominently defined, in the majority there is no 
great difficulty in assigning them to one or another class. The three 
forms are: 

1. Catarrhal or inflammatory phthisis : " Desquamative pneumonic 
phthisis." (Buhl.) Chronic broncho-pneumonia. 

2. Fibroid phthisis. Cirrhosis of the lung. Chronic pneumonic 
phthisis. Bronchial phthisis. Chronic interstitial pneumonia. 

3. True primary tuberculosis. Tubercular phthisis. Tubercular 
pneumonia. (Da Costa.) 

On the clinical recognition of these three varieties, Dr. Alfred L. 
Loomis says : 

If a case of phthisis present himself for examination, and it is found 
that the disease began with the ordinary symptoms of a cold, and that 
this cold periodically improved and relapsed, but that the cough never 
left him, but became more pronounced and deepened into what we 
usually find in advanced phthisis, accompanied with emaciation and 
occasional haemoptysis, we are in a position to say that the patient 
presents the usual characteristics of catarrhal phthisis. 

If, however, he gives a history of persistent cough for many years, 
as is found in chronic bronchitis, and eventually furnishes the rational 
history of advanced phthisis, with the presence of cavities in the lung, 
we may consider him as having the disease of the fibrous form, in which 
cavities are the result of dilated bronchi. 

Finally, if the patient says that an early symptom was emaciation, 
with impaired digestion, accompanied by a dry, hacking cough, and 
if, moreover, there was a steady rise in the temperature, we are justi- 
fied in suspecting the presence of tubercular phthisis. 

Prof. Austin Flint* contended that there is no pathological dis- 
tinction between the catarrhal and tubercular form of phthisis. The 
rare form of pulmonary phthisis, characterized by great predominance 
of interstitial growth, leading to notable diminution of the volume of 
lung by atrophy and dilatation of bronchial tubes, may be conveniently 
considered under a separate heading, as "fibroid" phthisis. Acute 

* Pepper's System of Medicine, Vol. iii., p. 391. 



1 66 



DIFFERENTIAL DIAGNOSIS. 



miliary tuberculosis may complicate either of these forms, or occur as 
a primary disease running a rapid course. 



THE FORMS OF PHTHISIS— CHRONIC CATARRHAL 

PNEUMONIA. 



Period of Invasion . 



Temperature 



Physical Signs 



Precursory catarrh, sometimes pneumonia, 
croup, measles, or other inflammatory disease ; 
cough "deepens," proceeding from the trachea 
to the alveoli and bronchioles, indicated by 
dark yellow streaks in the sputum. Fever and 
wasting not marked at outset. Haemoptysis 
not common at this period. 

The hectic is more of a remittent or intermit- 
tent than of a continued type ; with a range of, 
say, i.i° C. between evening and morning tem- 
perature; the evening elevation being a con- 
stant feature. 

The fever may present all possible variations 
in the same individual. A sudden accession 
may be regared as an indication of some fresh 
inflammatory process ; e. g. y pleuritis, pneu- 
monia. 

With marked evening rise of temperature, 
the rate of respiration does not correspondingly 
accelerate; hardly ever more than six or eight 
breaths per minute. 

In the first stage, feeble, harsh or puerile res- 
piratory sounds are heard, with all the signs of 
catarrh at apices and elsewhere. 

Dulness usually marked; when its area ac- 
cords with the other signs it is a comparatively 
favorable feature. 

The presence of lobular infiltration may, in 
some cases, cause a hollow or tympanitic note. 

" Cracked-pot" resonance over a cavity with 
thin walls. 

Fremitus is intensified over cavities connect- 
ing with bronchi and containing air. 

Bronchial respiration, bronchophony, and 
sonorous rales are heard after extensive indura- 
tion. 



DISEASES OF THE RESPIRATORY APPARATUS. 



6/ 



THE FORMS OF PHTHISIS— CHRONIC CATARRHAL 
PNEUMONIA.— Continued. 

General Nutrition . Not impaired in the early stage, but when 
cavities form, hectic and emaciation set in and 
we have " pneumonic phthisis." 

May continue for years, until pneumonic 
phthisis is developed, when it lasts only a few 
months. 

COMPARISON OF THE FORMS OF PHTHISIS. 



FIBROID. 

More or less dyspnoea, gradually 
increasing. Cough worse in win- 
ter, sometimes absent in summer. 
Haemoptysis frequent. Pulse 

slightly rapid, perhaps irregular. 
Expectoration often profuse, mu- 
cous or muco-purulent. No bacilli 
in expectorated matters. 



Elevation of temperature and 
other febrile symptoms very varia- 
ble, sometimes wholly absent (Bris- 
towe). No special type. 



Notable dulness on percussion, 
resonance sometimes tympanitic. 
Respiration bronchial, or broncho- 
vesicular. Bronchophony and in- 
creased vocal resonance. The af- 
fected side becomes contracted 
either entirely or in part. 

Bronchial dilatation (fusiform) 
gives the physical sign of a cavity. 

Not incompatible with apparent 
good health. 

Duration indefinite. 



TUBERCULAR. 

Commences in the alveoli, bron- 
chioles, or connective tissue. Pal- 
lor, fever, emaciation and night- 
sweats early. Cough hoarse and 
hard, voice hoarse or inaudible, dis- 
tressing laryngitis. The sputa re- 
iain the crude character of the 
mucous sputa of acute bronchitis, 
Bacillus tuberculosis (Koch) found 
in sputum.* Spleen somewhat en- 
larged. 

The hectic is of a continued type ; 
temperature always above normal, 
but not much higher in the evening 
than in the morning; i. e., the re- 
missions not well marked ; more- 
over, it resists treatment. 

Signs not well marked, not suffi- 
ciently so to account for the symp- 
toms. Solidification not extensive. 
Expansion unequal. 



Cavities form after softening; 
with destruction of lung tissue. 
Health obviously impaired. 



Lasts about one year. 



*For method of detecting the bacillus tuberculosis, see page 65. 



1 68 DIFFERENTIAL DIAGNOSIS. 

THE DIAGNOSIS OF INCIPIENT PHTHISIS. 
With the exception of the detection of the tubercle bacilli, there is 
no absolutely sure symptom of phthisis previous to percussion dull- 
ness, but a very strong presumption of its approach can be drawn from 
the presence of the following physical changes : 

1. Emaciation. Where there is progressive emaciation without as- 
signable cause, and especially if the appetite continue good, phthisis 
should always be suspected. The loss of flesh first shows itself in a 
retraction of the skin over the cheeks, a thinning of the lips and ears, 
and a pinched appearance of the nose. The nostril on the affected 
side is usually slightly more dilated than the other. 

2. Ancemia, seen in the bluish hue of the sclerotic, and in the pallor 
of the cheeks. 

3. Sore throat and hoarseness. Avery early symptom. On exami- 
nation the pillars of the fauces are found hyperaemic, the throat con- 
gested and the bronchial glands enlarged. 

4. Swelling of mucous membrane of lary?ix, especially forming a tur- 
ban-shaped epiglottis, which at the same time assumes a horse-shoe 
bend ; and pyriform enlargement over the arytenoid cartilages (Seiler).* 

5. Depression of the acromial end of the clavicle, on the affected side. 
In health the acromial end is slightly higher than the sternal end. 

6. Rheumatoid pains in the arms coming suddenly at night or in the 
early morning, not increased on moving the arm. 

7. Pityriasis versicolor, in the form of pale yellow or reddish spots 
appearing on the skin of the chest, neck and arms. This is considered 
by Aufrecht a very characteristic symptom. 

8. In regard to the breathing, what is considered as suspicious are 
weak, jerking, " cogged-wheel," or sonorous sounds, rough breathing, a 
lengthened strong expiration after soft inspiration, especially when 

,in circumscribed regions these sounds differ from those on the other 
."■side of the chest. The most appropriate spot to note the duration of 
^expiration is over the larynx or trachea. In proportion as the tuber- 
cular deposit is more extended, the expiratory murmur becomes more 
tubal in quality and higher in pitch (Armor). In the normal chest, 
.the respiratory sound becomes weaker in the supra-spinous region 

* Proceedings Philadelphia Co. Medical Society, Vol.ii, p. 101, Philada., 1880. 



DISEASES OF THE RESPIRATORY APPARATUS. 1 69 

outward from the vertical column. Dr. Heitler considers it, there- 
fore, strong evidence of incipient pulmonary phthisis if the respiratory 
sounds during expiration are more sonorous over these regions than 
near to the vertebral column.* 

9. Unequal expansion of chest is an early sign of commencing disease 
of the apex. The expansion is less on the diseased side. 

10. Alterations in temperature curve frequently take place early. The 
temperature may be low, but the characteristic range will be : (i) a 
marked rise after 2 p. m. ; (2) a rapid fall after 10 p. m. ; (3) minimum 
about 7 a. m.; (4) recovery to normal about 10 a. m. (C. T. Williams). 
Such a curve must always excite grave suspicions. 

11. Rapidity of pnlse. A persistent and sustained increase in the 
pulse rate, without cardiac disease, is a valuable rational sign, present 
very early in most cases. 

12. The cough of incipient phthisis is usually short, hacking, and 
dry, or with a slight, glairy, mucous expectoration only. From the 
presence of fragments of tho pulmonary fibrous tissue in the sputum, 
" we are sometimes enabled to suspect the existence of consumption 
before the physical signs of even its early stages are well defined." 
(Da Costa.) f 

13. Hcemoptysis. The appearance of haemoptysis is always a serious 
element of diagnosis. Light, frothy, red blood, rising without apparent 
exertion, is an indication which, in America at least, has proved of 
graver meaning the more it has been investigated.^ On the other 
hand, cases will be met with sometimes, in whom there may be con- 
siderable haemoptysis, with marked dulness at the apex, without as- 
sociation with tubercle.§ 

* Dobell's Reports on Diseases of the Chest, 1877. 

■f To examine sputa for elastic fibres, mix it with a soda solution : 

R . Liquor sodse, I part. 

Aquae destill., 2 parts. M. 

And boil for four or five minutes. Then dilute with an equal quantity of distilled water, 
and pour into a flat porcelain vessel. The particles suspended in the water may then be 
taken out and examined under the microscope. The fibres in this process are brown, 
slightly reticulated, and a fraction of a millimetre in length (Sokolowski). 

J See second Report of the New York Mutual Life Insurance Company, 1877. 

\ See Prof. Da Costa, in Medical and Surgical Reporter, July 13, 1878. 



170 



DIFFERENTIAL DIAGNOSIS. 



14. Clubbing of the finger ends, when associated with incurvation of 
the sides and tips of the nails, means obstruction of the subclavian 
veins, which is one of the earliest effects of tuberculosis; but clubbing 
without this incurvation is rather against the probability of tubercle 
(Dobell). 

15. Amennorrhea is, in young females, often one of the earliest signs 
of phthisis. 

16. A red line is occasionally noticed on the gums at the base of the 
teeth. 

17. Arthritis. M. Laveran* has drawn attention to the occasional 
occurrence of arthritis as the first symptom of a general tuberculosis. 

DIAGNOSIS BETWEEN INCIPIENT PHTHISIS AND 
BRONCHITIS. 



INCIPIENT PHTHISIS. 

1. The cough commences grad- 
ually, without marked disturbance 
or coryza, often preceded by slight 
loss of flesh and strength. 

2. The cough is generally dry 
and hacking at commencement, 
followed by the expectoration of a 
thin mucous fluid, which soon be- 
comes thick and opaque, or is 
slightly streaked with blood. 

3. Examination by the micro- 
scope shows portions of lung tis- 
sue (yellow elastic fibres) in the 
sputa. 

4. Pain of a wandering character 
about the chest, especially under 
the clavicles or between the shoul- 
ders. 

5. Evening rise of temperature. 



* Le Progres Medical, October 25, 1876. 



BRONCHITIS. 

1. The cough commences sud- 
denly, and is usually ushered in 
by feverishness and coryza. 

2. The cough is accompanied 
with expectoration almost from the 
first; generally abundant; frothy 
or muco-purulent; not rarely 
blood-stained. 

3. No evidence of destruction of 
lung tissue. 



4. A feeling of tightness and 
rawness behind the sternum, ag- 
gravated by coughing. 

5. Elevation of temperature not 
particularly marked toward even- 
ing. 

Quoted by Dr. M. Anderson. 



DISEASES OF THE RESPIRATORY APPARATUS. 



71 



DIAGNOSIS BETWEEN INCIPIENT PHTHISIS AND 
BRONCHITIS— (Continued^ 



INCIPIENT PHTHISIS. 

6. The morbid physical signs 
usually confined to upper lobe of 
one side; are very persistent, and 
if on both sides at first, apt to 
subside on one and increase on 
the other. 

7. Family history and general 
appearance indicate tuberculous 
cachexia. Most frequent in youth. 

8. Essentially chronic. 



9. Bacillus 
in sputa. 



tuberculosis occurs 



BRONCHITIS. 

6. Morbid signs usually predom- 
inating in the lower lobes; are on 
both sides; are of temporary du- 
ration, and subside gradually and 
equally on both sides. 

7. No marked hereditary tend- 
ency; common at all ages. 

8. Has an acute beginning. 

9. No bacilli in sputa. 



While these points of difference between tubercular disease and ca- 
tarrhal inflammation of the mucous membrane lining the bronchial 
tubes are in the main reliable, yet it must not be forgotten that chronic 
bronchitis is often attended by structural changes in the lung, leading 
in one set of cases to increase of connective tissue, with dilated bron- 
chiae — fibroid degeneration, chronic, broncho-pneumonia — and in an- 
other to deposits, chiefly epithelial, in the air-cells, producing spots of 
consolidation. 

The general clinical history of the three stages of phthisis may be 
summarized in the following brief table : 



172 DIFFERENTIAL DIAGNOSIS. 

PULMONARY PHTHISIS. (CHRONIC TUBERCULAR PNEUMONIA.) 



STAGE OF 
DISEASE. 



1st stage 

(incipient). 
Stage of 
invasion. 



2d stage 

(confirmed). 
Stage of 

deposit 



3d stage 
(advanced). 

Stage of soft- 
ening and 
formation of 
cavities. 



SYMPTOMS. 



PHYSICAL SIGNS. 



Cough at first dry, then 
with expectoration of mu- 
cus, frequently streaked or 
dotted with blood, or with 
copious haemoptysis. Dys- I 
pncea. Pains in the var- 
ious parts of the chest, | 
especially on the affected I 
side. Dislike to fatty ar- 
tides, and other dyspeptic 
symptoms ; tendency to 
vomiting after paroxysms 
of coughing. Night- 
sweats. Emaciation. In 
females, disturbance of the 
catamenial functions. Oc- ! 
casionally hectic. 

Cough more severe, with 
puriform expectoration, of 
a yellow or greenish hue, 
and often bloody. Pro- 1 
fuse night-sweats and rap- j 
idly progressive emacia- 
tion. Pinched and anxious 
expression. Loss of ap- 
petite. Thirst. Diarrhoea. 
Sometimes hectic. 

Cough rather looser, still 
with puriform (nummular) 
expectoration, or attacks 
of copious haemoptysis. 
Extreme emaciation and 
debility, with or without 
night-sweats. Voice 
husky and hollow. Aph- 
thae on mouth and fauces. 
Hectic. Clubbed fingers 
and talon-like nails. 



Diminished movements. 
Increased vocal fremitus. 
Loss of percussion reson- 
ance, rise in pitch, or a 
boxy, wooden note be- 
neath the clavicle or in 
the interscapular region. 
Feeble, coarse, or inter- 
rupted vesicular murmur, 
with prolonged expiration. 
Increased vocal reson- 
ance. Occasional sibilus 
or creaking friction sound. 
Heart sounds abnormally 
loud over affected side. 
Subclavian murmur. Pue- 
rile (exaggerated) respira- 
tion on sound side. 

Greater diminution ofmove- 
ment of the affected side, 
and some amount of flat- 
tening. Increased vocal 
fremitus. Increased dul- 
ness, extending down- 
ward. Bronchial breath- 
ing, mixed w T ith mucous 
rales or with click at the 
end of each inspiration. 
Bronchophony. 

Scarcely any movement of 
the affected side. Marked 
flattening. Increased 
vocal fremitus. Dulness 
less marked. Box-like 
resonance or cracked-pot 
sound. Cavernous breath- 
ing, with gurgling and 
splash on cough. Occa- 
sionally metallic sounds. 
Pectoriloquy. 



DISEASES OF THE RESPIRATORY APPARATUS. 1 73 

PHTHISIS— (Continued). 

COMPLICATIONS NOT RESTRICTED TO ANY PARTICULAR STAGE 

OF PHTHISIS. 

The chief of these are : Affections of the larynx and trachea, espe- 
cially ulceration ; bronchitis, intercurrent pneumonia, or pleurisy ; 
perforation of the pleura, with pneumo-hydrothorax or empyema ; en- 
largement of the external absorbent glands, or of those in the chest 
and abdomen ; tubercular peritonitis ; ulceration of the intestines, es- 
pecially the ileum ; fatty or amyloid liver ; fistula in ano ; various 
forms of Bright's disease ; diabetes ; pyelitis ; tubercular meningitis, 
or tubercle in the brain, and thrombosis of the veins of the legs. 
POST-MORTEM APPEARANCES. 

First stage. Lesions most marked at, or even confined to, one apex, 
where are to be seen gray, semi-transparent nodules, varying in size 
from a small pin's head to a hemp-seed ; the lung-tissue around these 
nodules may be healthy, but is generally hyperaemic and congested, 
slightly increased in density. In more advanced cases, in addition to 
the miliary nodules, there may be small yellow masses, less defined, 
but larger than the gray variety. Both kinds may either be scattered 
or several in one group, forming a considerable mass. 

Second stage. Commencement of caseation and softening in the 
centre of the consolidated portions, inflammation of the surrounding 
parenchyma, together with obliteration of the blood-vessels and for- 
mation of cicatricial tissue. 

Third stage. Cavities of various sizes and forms, and either single or 
numerous, generally containing puriform fluid. Ulceration and dila- 
tion of the bronchial tubes. Lung indurated and puckered in propor- 
tion to chronicity of disease. 

ACUTE PHTHISIS,* ACUTE MILIARY TUBERCULOSIS, 
GALLOPING CONSUMPTION. 

The formidable disease known under these names is probably, as 
M. Bouchut remarks, more common than is generally supposed, as it 
is generally mistaken either for capillary bronchitis or typhoid fever, 

* Austin Flint criticises this application of the word, since phthisis means an essentially 
chronic process. 



174 DIFFERENTIAL DIAGNOSIS. 

especially the latter. Its duration is brief, sometimes less than a fort- 
night (Da Costa), and its termination almost invariably fatal. Its 
features are thus so entirely distinct from the chronic form, from the 
clinical point of view, as to really constitute it a separate disease. 

Its onset is marked by chills and feverishness, nausea, vomiting and 
diarrhoea. There is a rapid pulse; dyspnoea; slight pain in the chest; 
cough, usually with profuse expectoration. Great exhaustion, sweats, 
rapid emaciation, and delirium, soon follow. One on both lungs ex- 
hibit unusual dullness, while the auscultatory sounds differ greatly in 
different cases. The symptoms often simulate typhoid fever, so as to 
distract attention from the pulmonary lesion. 

The following are the marked diagnostic features of the disease : 

1. Facial expression. The countenance is livid, indicating plainly 
an impediment to the passage of blood through the lungs. In severe 
typhoid fever the cheeks are slightly flushed, the facial muscles trem- 
ulous, the eyes dull, and the mouth partly opened, presenting an ap- 
pearance characteristic of the disease.* 

2. The delirium of acute phthisis is restless and often violent, but 
the rambling and wild talk is connected usually with things present 
or near. In typhoid fever the delirium is generally muttering and low; 
the mind deals with things absent, and the patient " is like a man talk- 
ing in his dreams." (Watson.) 

3. The tongue in acute phthisis, at first covered with a white fur, 
soon becomes red, glassy and dry. In typhoid it usually changes to 
a brownish hue. 

4. The ophthalmoscope is a most positive aid to the diagnosis, ac- 
cording to M. Bouchut. In all cases of acute, general, miliary tuber- 
culosis, an ophthalmoscopic examination will reveal the presence of 
tubercular granulations in the choroid,f thus placing the nature of the 
disease beyond doubt. 

5. Abdominal symptoms. Diarrhoea and gastric and abdominal pains 
are often present in acute phthisis ; but the red spots of typhoid are 
not seen. 

6. Chest symptoms. Dyspnoea is present always, but the orthopncea 

* L. J. Woollen, American Practitioner, July, 1871. 
i -Medical Times and Gazette, January, 1875. 



DISEASES OF THE RESPIRATORY APPARATUS. 1 75 

of capillary bronchitis is rare. (Shaw.) The respiration is greatly- 
quickened, and the proportion to the pulse averages 1:3. (Walshe.) 
The presence of percussion dulness, a sinking in at the upper part of 
the ehest, and the occurrence of hemorrhage, are conclusive evidence 
of tubercle. (Da Costa.) 

7. The sputum shows the characteristic serous and muco-purulent 
character, and may contain the elastic fibres of lung tissue, and numer- 
ous bacilli. 

DIAGNOSIS OF SYPHILITIC PHTHISIS. 
The distinctive traits of this form of lung disease have been sepa- 
rately studied by Dr. MacSwinney, of Dublin, and Dr. Pentimalli, 
of Naples. From these and a recent article on syphilitic diseases of 
the lung by Dr. E. T. Bruen, of Philadelphia, in Pepper's System of 
Medicine, we derive the following scheme: 

1. Absence of hereditary tendency, of a phthisical habitus, and of 
preceding pulmonary affections. Phthisis may complicate syphilitic 
cachexia. 

2. History of syphilitic disease in other organs, and presence of the 
syphilitic cachexia in its tertiary stage. Substernal tenderness, thick- 
ening of the tibial periosteum or that of the head of one or of both 
clavicles. 

3. The disease never begins in the apex, and is limited in its seat, 
being unilateral and generally posterior. (Pentimalli.) The tendency 
to localization in portions of the lungs, leaving large areas free from 
disease, is of value in diagnosis. (Bruen.) 

4. Haemoptysis rare, febrile symptoms absent or slight. 

5. Slowness in development, the acuter phthsical symptoms not 
manifest. Emaciation less rapid than in phthisis. 

6. Exacerbations of pain during the night. 

7. A peculiarly fetid breath may be noticed. 

8. Reference of the feeling of oppression to the larynx rather than 
to the chest. 

9. Failure of ordinary measures, and improvement under specific 
medication. 



i/6 



DIFFERENTIAL DIAGNOSIS. 



BRONCHITIS, ACUTE AND CHRONIC. 

In most cases of bronchitis the inflammation is seated in the larger 
bronchial tubes. There is more or less swelling- of their lining mucous 
membrane, not generally sufficient to prevent a free passage to the 
tidal air. The characters of the acute and chronic form are set forth 
in the tables, in the following pages. 

There is a variety of chronic bronchitis, in which the material exu- 
ded on the surface of the air passages contains a large proportion of a 
fibrinous constituent which makes it tough and consistent, so that 
when expelled the substance appears as a perfect cast of the bronchial 
tube in which it was formed. This is called fibrinous bronchitis, and 
does not differ in pathology from the ordinary chronic variety, but is 
less susceptible to treatment. Its diagnosis is made from the appear- 
ance of the casts, and needs no further mention here. 

ACUTE BRONCHITIS. 



SYMPTOMS. 



PHYSICAL SIGNS. 



1st or Dry Chilliness, followed by fre- 



Stage. 



2d or Moist 
Stage. 



quent pulse and febrile 
symptoms; pains in limbs. 
Substernal pain. Hoarse 
dry cough. Feeling of 
oppression and tightness 
about the chest. 



Cough, with expectoration 
of frothy, transparent mu- 
cus, mixed with air-bub- 
b.les of various sizes, and 
occasionally tinged or 
streaked with blood. Ur- 1 
gent dyspnoea, often 
amounting to orthopncea. 
Lividity and febrile symp- 
toms increased. Restless- 
ness at night. 



Breathing hurried. Rhon- 
chal fremitus may be felt. 
Resonance on percussion 
unimpaired. Feeble vesi- 
cular murmur, mixed with 
rhonchus and sibilus. 
Puerile breathing in un- 
obstructed parts of lung. 
Vocal resonance not ma- 
terially altered. 

Breathing hurried. Rhon- 
chal fremitus may be felt. 
Resonance on percussion 
clear, or only ve%- slightly 
impaired. Feeble vesicu- 
lar murmur mixed with 
rhonchus, sibilus and mu- 
cous rales. Vocal reson- 
ance unaltered. 



DISEASES OF THE RESPIRATORY APPARATUS. 

ACUTE BRONCHITIS. 



177 



3d Stage. 
a. (Termi- 
nation fa- 
vorable.) 



SYMPTOMS. 



Gradual remission of the 
symptoms. Expectora- 
tion becomes thick, green- 
ish, and opaque, and 
sometimes nummulated. 



PHYSICAL SIGNS. 



Less amount of sonoro- 
sibilant and mucous rales, 
with return of normal 
vesicular breathing. 



In addition to the signs of 
the second stage, tracheal, 
rales may be heard. 



b. (Unfavora- Dyspnoea very urgent, signs 
ble.) of impending suffocation. 

Profuse cold sweats. Sink- 
ing, drowsiness and de- 
lirium. Less cough, ab- 
sence of expectoration. 

The. post-mortem, appearances are: Congestion of mucous membrane 
of bronchial tubes, with some degree of swelling and dryness of sur- 
face. 

Lungs do not collapse when the chest is opened ; nor do sections 
sink in water. The mucous membrane of the bronchi is red and swol- 
len, and the tubes filled with frothy, adhesive mucus. 

CHRONIC BRONCHITIS. 



SYMPTOMS. 

Two chief forms: the one char- 
acterized by the sputa being ex- 
pectorated with great difficulty, 
consisting of small, gray, semi- 
transparent pellets, and tending to- 
ward emphysema; in the other the 
sputa are abundant, mucopuru- 
lent, and brought up with ease; 
dilatation of the bronchi frequently 
associated with this form. The 
cough generally comes on at the 
approach of winter, with history 
of former attacks. Dyspnoea; 
lividity of surface; and in some 
cases the symptoms resemble those 
of chronic phthisis, as wasting, 
with night-sweats and hectic. 
12 



PHYSICAL SIGNS. 

Respiration labored and abdom- 
inal. Vocal fremitus not materially 
altered; rhonchal fremitus can gen- 
erally be felt. Impairment of 
resonance or a hyper-resonant: 
note, according as collapse of lung; 
and consolidation^, or. emphysema , 
predominate, the former most: 
marked at the bases, the latter ati 
the anterior part. Feeble vesicu- 
lar murmur. Rhonchus, sibilus, . 
and mucous rales. Vocal reson- 
ance varies. 



I78 DIFFERENTIAL DIAGNOSIS. 

The post-mortem appearances are : — 

Lungs generally much congested, presenting a dark livid hue, with 
portions collapsed, and others emphysematous. Bronchial tubes fre- 
quently dilated. Mucous membrane thickened, uneven, sometimes 
ulcerated, covered by a thick, puriform secretion, or sparingly coated 
by a tenacious, glairy, semi-transparent substance. 

The principal diseases with which bronchitis may be confounded are 
pneumonia, pleurisy, and pulmonary phthisis. But each of these is 
characterized by the presence of definite physical signs, which are not 
to be found in ordinary bronchitis. For instance, in this disease there 
is no disparity between the two sides of the chest in the resonance ob- 
tained by percussion, nor in vocal resonance, the bronchial whisper 
and fremitus. The swelling of the bronchial mucous membrane may 
cause some diminution of the intensity of the vesicular murmur; but 
as the affection is bilateral and the bronchial tubes on both sides are 
affected equally both in degree and extent, there is no appreciable dis- 
parity between the two sides. Sometimes temporary weakening or 
suppression of the murmur may be caused by a plug of mucus, which 
will be detected on a second examination (Flint), or by instructing 
the patient to cough, so as to dislodge it. 

CAPILLARY BRONCHITIS. 
Acute capillary bronchitis may, however, be taken for some of the 
forms of pneumonia, and in fact the descriptions of some writers would 
lead to the belief that they have committed this error. The following 
distinctions will make the diagnosis easy in most cases: — 



CAPPILLARY BRONCHITIS. 

Commences in the external air 
passages as a. common cold and 
extends downward. Usually pre- 
ceded by ordinary bronchitis. 

Always bilateral. 

Normal or exaggerated reso- 
nance on percussion, unless col- 
lapse has commenced. 

Sub-crepitant rales on both- sides 
of the chest. 



PNEUMONIA. 

Commences suddenly with a 
chill, and attacks the lungs directly. 
No antecedent bronchitis as a rule. 



Generally unilateral. 

Dulness on percussion more or 
less extensive at the outset. 



Crepitant rale over affected lung 
tissue. 



DISEASES OF THE RESPIRATORY APPARATUS. 



1 79 



CAPILLARY BRONCHITIS. 

Respiration not bronchial, 50 or 
more; pulse 150 or more. 

Muco-purulent expectoration; 
no plastic lymph. 

Dyspnoea intense ; cyanosis 
early. No pain or but little. 

Death from asphyxia; mortality 
more than half. 

A disease of children. 



PNEUMONIA. 

Respiration bronchial, 25 to 40 
per minute. Pulse 100 to 130. 

Rust-colored expectoration ; plas- 
tic lymph in pulmonary air cells. 

Dyspnoea less; cyanosis late if 
at all. Pain in the side. 

Death from asthenia; mortality 
ten per cent. 

A disease of adult life. 



PNEUMONIA AND PLEURISY. 

Ordinary acute inflammation of the lungs in its early or first.stage 
is well marked by the presence of a moderate or slight dulness on 
percussion over the affected lobe, and the detection on auscultation of 
the crepitant rale. The latter is indeed not invariably present, but 
when it is, taken in connection with the symptoms, it is pathognomonic. 

Later in the disease the rust-colored expectoration of pneumonia on 
the one hand, and the physical signs of effused liquid into the pleural 
cavity in pleurisy on the other hand, offer distinctive features. 

The general clinical histories of the diseases are given in the follow- 
ing tables : — 

PNEUMONIA. 



1st Stage. 
(Engorge- 
ment.) 



SYMPTOMS. 



Single, severe rigor (or con- 
vulsions in children), followed 
by heat of skin. Increased 
frequency of pulse. Respira- 
tion greatly accelerated, with 
consequent disturbance of the 
pulse-respiration ratio. Dysp- 
noea. Pain in the side, in- 
creased by cough or deep in- 
spiration. Cough, at first dry, 
with rusty sputa about the 
second or third day. Inability 
to lie on affected side. Di- 
lated alae nasi. Herpes about 
lips. 



PHYSICAL SIGNS. 



Diminished movement 
on the affected side. 
Respiration abdom- 
inal. Vocal fremitus 
normal. Percussion 
note not materially 
affected. Feeble vesi- 
cular breathing. Fine 
crepitant rales, most 
frequently heard at 
base of lung and at 
the end of inspiration. 
Presence of pneumo- 
nococcus in the sputa. 



i8o 



DIFFERENTIAL DIAGNOSIS. 

PNEUMONIA— {Continued) 



26. Stage. 
(Red 
hepatization.) 



3d Stage. 
a (Gray 
hepatization.) 



or 



b (Resolu- 
tion.) 



SYMPTOMS. 



Increased distress and dysp- 
noea. Respiration and speech 
panting. Cough more urgent, 
and sputa still rust-colored, 
extremely viscid, and tena- 
cious. Absence or deficiency 
of chlorides in the urine. 



Aspect much distressed. Face 
pale and livid. Great failure 
of vital powers. Hectic and 
delirium. Cough continues, 
and the sputa are either ab- 
sent, or sometimes they re- 
main rust-colored; at others 
become like prune-juice, even 
fetid. 

Symptoms yielding about 7th 
day of disease. Cough less 
troublesome, expectoration 
easier. Patient evidently con- 
valescing. 



PHYSICAL SIGNS. 



Very slight movement. 
Vocal vibrations well 
marked. Dulness on 
percussion. Tubular 
breathing and bron- 
chophony, generally 
accompanied by some 
rales, if at the com- 
mencement of the 2d 
stage of a crepitant 
character, and after- 
ward of a mucous na- 
ture. 

Absolute dulness on 
percussion. Tubular 
breathing and bron- 
chophony, frequently 
with gurgling rales 
where the lung is dis- 
organized. 



Dulness diminishing 
by absorption. Bron- 
cho-vesicular breath- 
ing with crepitant 
redux rales yielding to 
normal vesicular mur- 
mur, and percussion- 
note. 



Post-mortem Appearances. — Lungs: 1st stage. Engorged with 
frothy andbloody serum. Dark-red color externally, and on section. 
Crepitating less, and heavier, than sound lung, but still floating in 
water. Pulmonary tissue slightly softened. 

2d. Red externally, red or mottled and granular on cut surface, and 



DISEASES OF THE RESPIRATORY APPARATUS. 



I8l 



of liver-like solidity. Easily torn, and with fluid exuding on pressure 
less abundant than in first stage, but thicker, and towards the end of 
this stage becoming purulent. Not crepitating, and sinking in water. 
3d. Reddish-yellow or gray. More soft and friable. Purulent 
fluid exudes from the cut surface; and, on pressure, the whole lung 
may be reduced to a pulp-like mass. 

PLEURISY. 
The symptoms of pleurisy are attributed to inflammation of the 
serous covering of the lungs, and is to be distinguished from passive 
effusion into the pleural sac, or hydrothorax, which is readily recog- 
nized by the following points of difference: 



PLEURISY. 

Due to inflammation (active). 

Has an acute beginning, accom- 
panied by stitch in the side, cough, 
constitutional disturbance, pyrexia, 
etc. 

May be traced to traumatic 
causes, or to exposure to wet and 
cold; or may complicate zymotic 
diseases. 

One side only affected, as a rule. 

Runs its course in a few days, 
terminating in chronic pleuritic 
effusion, or in absorption of fluid. 

No complications generally. 



HYDROTHORAX. 

Due to transudation (passive). 

Effusion takes place insidiously, 
without local or general symptoms, 
beyond those caused mechanically 
by pressure on the thoracic viscera. 

Due to blood disorder, accom- 
panying renal disease, or more 
rarely to obstruction to circulation 
by morbid growths, or valvular 
disease of heart. 

May be bilateral. 

Remains stationary for months, 
or may slowly increase. 

Accompanied by albuminuria, 
heart disease, and dropsy else- 
where in the body. 



1 82 



DIFFERENTIAL DIAGNOSIS. 



PLEURISY. 



or 



Pleurisy : 
1st Stage, 
Stage of Hy 
peraemia. 



2d Stage, or 
Stage of Ef- 
fusion. 



SYMPTOMS. 



Rigors, or more fre- 
quently mere chilli- 
ness. Sharp, stabbing 
pain in the side, in- 
creased by deep inspi- 
ration or cough, ac- 
companied by more or 
less tenderness on 
pressure. Breathing 
short and hurried. 
Respiration chiefly ab- 
dominal, with inability 
to lie on the affected 
side. Short, dry cough, 
or none at all. Pulse 
full and bounding. 
Febrile symptoms. 

Cough, dyspnoea, sense 
of weight and fullness 
of the affected side. 
Febrile symptoms less 
marked. Patient lies 
toward, not on, the af- 
fected side. Complex- 
ion inclined to be 
dusky. 



PHYSICAL SIGNS. 



Diminished movement on the 
affected side. Friction fre- 
mitus may sometimes be felt. 
Percussion sound not mate- 
rially altered. Vesicular 
murmur feeble and jerking 
in rhythm. To-and-fro-fric- 
tion sound. 



Almost total absence of move- 
ment of the affected side, 
which is unduly prominent, 
the intercostal spaces being 
obliterated or even bulg- 
ing. Integuments occasion- 
ally ©edematous. Vocal vi- 
brations absent. Complete 
dulness on percussion, most 
marked in the dependent 
portions of the chest, and 
sometimes altered by change 
of posture. Heart pushed 
over to sound side, and dia- 
phragm pushed down, so 
that the liver and stomach 
descend lower into the ab- 
domen than in health. Ves- 
icular murmur almost, or 
quite, absent. Frequently 
bronchial breathing near the 
spine. Voice sounds absent 
or feeble, except when the 
layer of fluid is thin, and then 
there may be segophony. 
No friction sound. Puerile 
breathing in sound lung. 






DISEASES OF THE RESPIRATORY APPARATUS. 



83 



PLEURISY— ( Continued). 



3d Stage (Res- 
olution after 
Effusion). 



SYMPTOMS. 



Gradual diminution of 
the cough, dyspnoea, 
and other symptoms. 
Returning ability of the 
patient to lie on the 
sound side. Gradual 
return of displaced or- 
gans to their normal 
position. 



The movement of the chest 
gradually increases. Return 
of vocal vibration and friction 
fremitus. The dulness on 
percussion diminishes from 
above downward, but the 
resonance generally remains 
box-like for a considerable 
period. Gradual restoration 
of the vesicular murmur, at 
first weak and distant, then 
somewhat harsh, and sub- 
sequently of a normal char- 
acter. Reappearance of the 
friction sound for a time. 
Pseudo rales occasionally to 
be heard. ^Egophonysome- 
etimes to be heard, more of- 
ten bronchophony, and ulti- 
mately normal vocal reso- 
nance. 



Post-mortem Appearances. — 1st stage. Pleura opaque and drier 
than natural, roughened and highly vascular, and presenting a close 
network of blood-vessels with ecchymoses. 

2d. Fluid either serous or purulent, mixed with shreds of creamy 
lymph, in the cavity of the pleura. Lung pushed upward and backward 
towards the spine, its surface coated with a layer of lymph of the same 
kind as that mixed with the fluid. The lung collapsed and carnified. 

3d. If the effusion has been of long duration the lung remains carni- 
fied and bound down by adhesions, and the chest-wall undergoes re- - 
traction or depression, the ribs overlap, and there is more or less laterall 
curvature of the dorsal spine toward the diseased, and of the lumbar- 
toward the healthy side. 

The diagnosis can be made by drawing off part of the fluid from the- 
chest by means of a hypodermic syringe. If purulent, it should be 
evacuated; if allowed to remain it may lead to amyloid changes in the: 
liver and kidneys. 



PHYSICAL SIGNS. 



1 84 



DIFFERENTIAL DIAGNOSIS. 



The effusion may become purulent at first; there are no reliable 
means of recognizing the exact time when this occurs, but later it 
assumes all the characteristics of empyema, as follows : 



SYMPTOMS. 



Empyema. 



More decided febrile 
disturbance of a hectic 
type; night-sweats. 
Morning remission and 
evening exacerbations, 
Face puffy and semi- 
transparent. Clubbing 
of the finger ends. If 
pointing inwardly, 
abundant purulent 
sputa. 



PHYSICAL SIGNS. 



The physical signs are those of 
the stage of effusion, except 
that there is entirely absent 
vocal fremitus and increased 
resistance upon percussion. 
The diagnosis is often to be 
determined only with the 
aid of the aspirator, or the 
hypodermic needle. 






DIAGNOSIS BETWEEN PLEURISY WITH EFFUSION AND 
PNEUMONIC CONSOLIDATION. 



PLEURISY. 

1. Begins with chilliness or sev- 
eral slight rigors. 

2. Sharp, catching, stitch-like 
pain in the side. 

3. Cough, dry or with little mu- 
cous expectoration, very painful, 
and repressed by the patient. 

4. Pyrexia is not great and the 
skin maybe moist. 

5. Excretion of chlorides not 
affected. 

6. Pulse-respiration ratio not af- 
fected, except in excessive effu- 

: sion. 

7. Affected side rounded ; dis- 
placement of heart. 



PNEUMONIA. 

1. Begins with a severe and 
protracted rigor. 

2. Pain does 



breath 



not catch the 
is more of a dull character. 



3. Cough frequent and severe, 
with rusty, viscid expectoration. 

4. Great febrile disturbance, 
skin hot and pungent. 

5. Diminution or absence of 
chlorides in the urine. 

6. Pulse-respiration ratio may 
fall to 2 : 1. 



7. No alteration in shape of the 
chest or of the intercostal spaces ; 
heart not displaced. 



DISEASES OF THE RESPIRATORY APPARATUS. 



I8 5 



DIAGNOSIS BETWEEN PLEURISY WITH EFFUSION AND 
PNEUMONIC CONSOLIDATION— {Continued). 



PLEURISY. 

8. Feeble or absent vocal fremi- 
tus. 

9. Absolute dulness on percus- 
sion, transcending the median line 
in front. 

10. Feeble or absent vesicular 
breathing; bronchial breathing at 
the root of the lung. 

11. Vocal resonance absent be- 
low, sometimes aegophonic above. 

DIAGNOSIS BETWEEN PNEUMONIA AND PULMONARY 

APOPLEXY. 



PNEUMONIA. 

8. Vocal fremitus usually much 
intensified. 

9. Less intense dulness, not 
transcending the median line. 

10. Marked tubular breathing, 
often of a metallic character. 

11. Loud bronchophony. 



PULMONARY APOPLEXY.* 

Nearly always associated with 
'heart disease or pyaemia. May 
follow traumatism. 

Onset sudden. Fever absent, ex- 
cept in pyaemia. Pulse irregular 
and intermittent. Signs of the 
rupture of a vessel in the lungs. 

Expectoration blackish, with 
small dark clots. Hemorrhage 
may be profuse. 

Dyspncea severe at first, after- 
wards diminishing. 

Dulness distinctly circum- 
scribed ; respiration bronchial, with 
moist rale. 

A peculiar acid and alliaceous 
odor to the breath " like the smell 
of tincture of horse-radish" (Gue- 

NEAU DE MUSSY). 

Usually fatal if hemorrhage is 
large. 

* Pulmonary infarction presents symptoms 
marked. 



PNEUMONIA. 

Generally an independent disease 
in robust individuals. Due to in- 
fection or exposure. 

Onset with malaise and chill. 
Fever. Pulse rapid. 



Expectoration .rust-colored ; no 
clots. 

Dyspncea gradually grows in in- 
tensity. 

Dulness larger and extending. 
Crepitant rale. Tubular breath- 
ing, bronchophony. 

Not present. 



Prognosis usually favorable un- 
der proper treatment. 

like those of pulmonary apoplexy, but less 



1 86 DIFFERENTIAL DIAGNOSIS. 

THROMBOSIS OF PULMONARY ARTERY. 

The symptoms of an immediately fatal attack are : Sudden extreme 
dyspnoea with open tubes, cough and thoracic pain, lividity or pallor, 
rapidly failing pulse, cold sweats, intense anxiety, and attacks of faint- 
ing or unconsciousness, with or without spasms. 

In the diagnosis, the suddenness of the conditions being of the chief 
interest, all those forms of suffocation requiring time for their produc- 
tion may be disregarded, and there remain : — 

i. Closure of the greater air-passages or of a large number of small 
ones, from without or from within. 

2. Nervous lesions, particularly intra-cranial, affecting respiration 
and circulation. 

3. Obstruction to the pulmonary circulation from emboli, of blood 
and air particularly (fat being more gradual in its effects). 

Physical and rational evidence of open air passages eliminate the 
first series. In intra-cranial origins of suffocation the predominant 
early symptoms are those of cerebral anaemia, namely, pallor, relaxed 
muscles, disturbed hearing and vision, contracted pupils, fainting and 
convulsions. Dyspnoea may sometimes precede these symptoms, but 
it is not of so severe a character as in the other series. 

In favor of the third is the history of an antecedent thrombus, or of 
a disease of the heart likely to be associated with thrombosis, or of 
septicaemia. Pulmonary thrombosis may also occur after child-birth, 
and be mistaken for hysteria. Asthma presents such marked clinical 
features, that due attention to these will prevent any difficulty in diag- 
nosis, except where it occurs as a complication. 

ASTHMA. 



SYMPTOMS. 



PHYSICAL SIGNS. 



There may be premonitory 1 Chest generally distended, though 
symptoms, such as gradually in- J there is scarcely any expansive 
creasing dyspnoea or the passing movement. Recession of the in- 
of a large quantity of limpid urine; tercostal spaces, supra-sternal and 
but the attacks usually come on supra-clavicular fossae and epigas- 
suddenly at an early hour in the trium during inspiration, which is 
morning; the patient awakes in a short and jerky, while expiration 
start, with a sensation of suffoca- ' is prolonged and wheezing. Vocal 



DISEASES OF THE RESPIRATORY APPARATUS. 



87 



AST H M A— ( Continued) . 



SYMPTOMS. 



tion and oppressiveness of the 
chest ; he either sits upright in 
bed, or sometimes stands holding 
on to a piece of furniture, so as to 
bring into play the accessory mus- 
cles of respiration. Countenance 
pale and anxious ; in bad cases cy- 
anotic. Skin covered with sweat ; 
extremities cold. Pulse frequently 
feeble. The attacks generally ter- 
minate with the expulsion of tough, 
ashy gray pellets of mucus. 

Post-mortem Appearances. — The appearances found after death are 
principally the result of chronic bronchitis and emphysema, with dila- 
tation of the right side of the huart. 

PNEUMOTHORAX. 

This condition is commonly found associated with a serous effusion 
— pneumo-hydrothorax; but occasionally presents itself as an inde- 
pendent affection. The characteristics of the two forms are as follows : 



physical signs. 

vibration not markedly affected. 
Rhonchal fremitus may be felt. 
Resonance on percussion increased 
all over the chest. Almost com- 
plete absence of vesicular murmur. 
Every variety and kind of sibilus 
and rhonchus, whistling, squeak- 
ing, cooing, snoring sounds, and 
occasionally mucous rales towards 
the termination. 



Symptoms. 



PNEUMOTHORAX. 



Generally sharp, stabbing, 
pain, with the sensation 
of something having giv- 
en way. Urgent dys- 
pnoea and evidences of 
shock. More or les cy- 
anosis. Posture assumed 
by patient varies. Pulse 
frequent, weak and small. 
Respiration may be 40 
to 60 in the minute. 
Troublesome cough 
without expectoration. 
In some cases of phthi- 
sis, or where there are 
extensive pleural adhe- 



PNEUMO-HYDROTHORAX. 



Symptoms the same, ex- 
cept that the cough is 
usually attended by fe- 
tid, or muco-purulent 
expectoration. The pa- 
tient lies on or toward 
the affected side. 



1 88 



DIFFERENTIAL DIAGNOSIS. 



PNEUMOTHORAX-^ Continued) 



Symptoms. 
Continued. 



Physical Signs. 



Post-mortem 
Appearance. 



PNEUMOTHORAX. 



sions, pneu mothorax 
may come on quite im- 
perceptibly. 

Dilatation of the affected 
side, with obliteration or 
bulging of the intercos- 
tal spaces. Movements 
of respiration diminished 
or absent. Increased 
elasticity of the walls of 
the chest. Feeble or 
absent vocal fremitus. 
Clear tympanitic reson- 
ance on percussion. If 
the amount of air is ex : 
treme there may be 
high-pitched dullness. 
No true vesicular mur- 
mur; bronchial breath- 
ing may be heard along 
the spine. Amphoric 
sounds, with inspiration, 
voice, and cough, also a 
metallic echo; the bell 
sound may be elicited. 
The neighboring viscera 
are displaced to a vari- 
able degree. 

Lung collapsed, lying 
near vertebral column, 
unless bound down by 
old adhesions to some 
other part of the chest 
wall. The gas is com- 
posed chiefly of carbonic 
acid and nitrogen, con- 
taining but little oxygen, 
and occasionally some 
sulphureted hydrogen. 



PNEUMO-HYDROTHORAX. 



Same as in simple pneu- 
mothorax, except that 
percussion is dull in the 
lower part of the chest, 
and tympanitic above 
the level of the fluid. 
Metallic tinkling and 
splashing sounds on suc- 
cussion are also fre- 
quently hear.d. 



Lung collapsed. Air, 
mixed with fluid, i n 
pleural cavity. Mostly 
arises as a termination 
to phthisis, a superficial 
cavity becoming rup- 
tured. May occur in 
pneumonia, emphysema, 
or gangrene of the lung, 
and more rarely in other 
diseases. 






DISEASES OF THE RESPIRATORY APPARATUS. 



189 



EMPHYSEMA. 
This affection presents itself in two forms, the vesicular and the in- 
terlobular, which are distinguished as follows : 



Symptoms. 



Physical Signs. 



VESICULAR EMPHYSEMA. 

Habitual shortness of 
breath, with occasional 
paroxysms of urgent 
dyspnoea, most frequent- 
ly supervening on ca- 
tarrh. Cough, with or 
without expectoration of 
thin, transparent, frothy 
mucus. In the last stage 
of the disease there are 
symptoms due to inter- 
ference with the circula- 
tion, as palpitation, cya- 
nosis, general dropsy, 
and congestion of the 
abdominal viscera. The 
disorder is essentially 
chronic in its course, and 
may progress so slowly 
as not to materially 
shorten life. It gener- 
ally occurs in persons 
who are otherwise vig- 
orous, and is hence sup- 
posed to grant immunity 
from consumption. 

Chest " barrel-shaped " 
and almost circular. 
Sternum projecting for- 
ward. Scapulae and 
clavicles raised and ill- 
defined. Ribs more hor- 
izontal, and intercostal 
spaces widened. Res- 
piration abdominal. 



INTERLOBULAR EMPHYSEMA. 



Urgent dyspnoea and op- 
pression, generally oc- 
curring suddenly after 
some violent effort of 
coughing, the subcutan- 
eous areolar tissue fre- 
quently becoming cede- 
matous. 



No marked change of con- 
tour of the chest. Per- 
cussion tympanitic over 
the affected part. 



190 



DIFFERENTIAL DIAGNOSIS. 

EMPHYSEMA— {Continued). 



Physical Signs. 
Continued. 



Post-mortem 
Appearance. 



VESICULAR EMPHYSEMA. 



Movement of chest much 
diminished. Heart beat- 
ing in the epigastric re- 
gion. Resonance on 
percussion greatly in- 
creased or tympanitic. 
Feeble inspiration, pro- 
longed expiration, the 
former wheezing, the lat- 
ter generally with rhon- 
chus or sibilus. Vocal 
fremitus and resonance 
usually deficient. 

Lung does not collapse 
as usual when the chest 
is opened, but, on the 
contrary, may rise up 
and bulge out of its cav- 
ity. It is pale and anae- 
mic, and does not crepi- 
tate when pressed, but 
feels soft and downy, 
and is drier than ordin- 
ary. The air cells are 
dilated, or several have 
become one cavity from 
the rupture of the septa 
between them. Cells 
vary from the size of a 
millet-seed to that of a 
swan shot, 



INTERLOBULAR EMPHYSEMA. 



or larger. 



Bead-like bubbles of air 
seen through the pleura, 
or partitions between the 
lobules much widened. 
Sometimes air is found 
beneath the areolar tis- 
sue of the neck. 



CANCER OF THE LUNG. 
The principal obstacle in recognizing this disease is the liability to 
confound it when primary and unilateral (as it usually is when primary ) 
with phthisis. Similar cough, emaciation, haemoptysis, night sweats, 
etc., occur in both. The points of difference are : — 






DISEASES OF THE RESPIRATORY APPARATUS. 

PHTHISIS. 



191 



PULMONARY CANCER. 

Sides of chest more markedly 
asymmetrical; the tumor may bulge 
through the intercostal spaces. 

Percussion dulness very great; 
may extend beyond median line. 

Frequent changes in the signs 
of auscultation, rales, bruits, etc. 

Haemoptoic sputa/ " resembling 
currant jelly." 

Pain constant, severe, lancinat- 
ing. 

Cancerous cachexia, tinge of 
skin, etc. 

Temperature may be subnormal. 



One side may be sunken ; never 
bulging. 

Percussion dulness moderate ; 
never extends beyond median line. 

Changes much more gradual. 

Sputa never present this appear- 
ance. 

Pain variable, intermittent. 
Absent. 



Temperature usually elevated. 
Hectic. 



Pulmonary cancer is sometimes so masked that its diagnosis re- 
quires the closest attention. It may be present without the character- 
istic sputa, without cachexia, and even without pain at cancerous spot* 
Such instances are, of course, very rare. 

It is liable to be mistaken for chronic pleurisy or vice versa. The 
distinguishing features are, that in cancer there is an absence of the 
complete consolidation of chronic pleurisy; the consolidation of the 
latter is at the lower portion of the lung; the expectoration of cancer 
is quite different from that of pleurisy and bronchitis ; and the previous 
history, both of the individual and his family, in cancer, points to this 
disease, while chronic pleurisy has as an antecedent an acute attack. 

The deposits of gummatous nodules in the lungs consequent on sec- 
ondary syphilis, together with the cachexia attendant on that disease, 
may simulate a cancerous deposit. The history of the case, the pres- 
ence of syphilitic signs in other organs and tissues, and the fact that 
cancers tend to spread and infiltrate the surrounding tissue, while the 
syphilitic nodule remains isolated and circumscribed, are the distinctive 
points. (For characters of syphilis of the lung see page 176.) 

* See case recorded in the Boston Medical and Surgical Journal, January, 1876. 



CHAPTER III. 

DISEASES OF THE CIRCULATORY APPARATUS. 

Contents. — The Precordial Region — Normal Sounds and Impulse of 
the Heart — Endocardial Murmurs — General Rules for the Diagnosis 
of Heart Diseases — Constitutional Symptoms of Heart Disease — Club- 
bi?tg of the Fingers — Differential Signs Between Ancemic and Organic 
Blood Murmurs — Pains at and near the Heart — Aphorisms Regard- 
ing Angina Pectoris — Differential Signs of Aortic Obstruction and 
Aortic Incompetency ; of Mitral Obstruction and Mitral Inco7npetency; 
of Pulmonary Obstruction and Tricuspid Regurgitation — Pericarditis 
— Diagnosis Between Acute Endocardial and Exocardial Sounds ; 
Between Cardiac Dilatation and Pericarditis with Effusion ; Between 
Simple Hypertrophy, Hypertrophy zvith Dilatation , and Simple Dila- 
tation — Fatty Degeneration of the Heart. 

The anatomical positions of the several parts of the heart are as 
follows : — 

RELATIONS OF THE HEART TO THE PRECORDIAL REGION. 



Apex of Heart . 

Base of Heart. . 
Tricuspid Orifice 

Mitral Orifice . 



SITUATION. 



Ordinarily found in health between fifth and 
sixth ribs on left side, about two inches below 
the nipple and one inch on its sternal side. 

On a level with the third costal cartilages. 

Extends from the junction of the fourth left cos- 
tal cartilage with the sternum, behind that bone 
to the articulation of it with the sixth right 
cartilage. 

To the left of the tricuspid valves, immediately 
behind the fourth costal cartilage ; but less su- 
perficially placed than the tricuspid. 
(192) 



DISEASES OF THE CIRCULATORY APPARATUS. 
THE PRECORDIAL REGION— (Continued). 



193 



REGION. 



Pulmonary Orifice 



Aortic Orifice 



SITUATION. 



Immediately behind the left border of the ster- 
num at the junction of the third costal cartilage 
with that bone. 

About half an inch lower than and to the right 
of the pulmonary orifice, behind the sternum, 
on a level with the third interspace. 

Let it be remembered that the tricuspid orifice is the most super- 
ficial, then the pulmonary, next the aortic, and deepest of all is the 
mitral orifice. Ranged from above downward, the pulmonary orifice 
comes first, then the aortic, then the mitral, and lastly the tricuspid. 

PHYSICAL EXAMINATION OF PRECORDIAL REGION. 



EXAMINATION BY 


SHOWS. 


Inspection 


Form of chest. 




Point at which the apex of the heart strikes the 




wall of the chest. 




Regularity of impulse, and extent over which 




it is perceptible. 


Palpation ..... 


Force, extent of diffusion, and regularity of im- 




pulse. 




Presence or absence of purring tremor or of 




friction fremitus. 


Percussion .... 


Extent and intensity of prsecordial dulness. 


Auscultation . . . 


Character of rhythm. 




Character of sounds, normal or abnormal. 



THE AREA OF SUPERFICIAL CARDIAC DULNESS 
Is roughly triangular in shape, the right side of the triangle being the 
mid-sternal line from the level of the fourth chondro-sternal articula- 
tion downward ; the hypothenuse being a line drawn from the same 
articulation to a point immediately above the apex-beat ; the base being 
a line drawn from immediately below the apex-beat to the point of 
meeting between the upper limit of liver dullness and the mid-sternal 
line (Dr. Gee). 

. 13 



i 9 4 



DIFFERENTIAL DIAGNOSIS. 
NORMAL SOUNDS AND IMPULSE OF HEART. 



SOUND. 



First Sound 
(Systolic). 



First Pause. 

Second Sound 
(Diastolic). 



Second Pause, 



Impulse. 



CHARACTER. 



Dull and pro- 
longed. 



Short and clear. 



POINT OF 
GREATER IN- 
TENSITY. 



Fourth and 
fifth intercos- 
tal spaces just 
within left nip- 
ple line. 



Base of heart, 
opposite the 
third right cos- 
tal cartilage. 



Between fifth 
and sixth ribs 
on left side, 
about one and 
a half or two 
inches below 
the nipple, and 
one inch to its 
inner side. 



CAUSE. 



Closure of au- 
riculo- ventric- 
ular valves, 
and, perhaps, 
muscular con- 
traction of the 
ventricles 
t h e m s elves ; 
also impact of 
apex against 
the chest- wall, 
and vibration 
of papillary 
muscles and 
chordae tendi- 



Sudden closure 
of the aortic 
and pulmon- 
ary valves. 



In part due to 
the tilting up- 
ward o f t h e 
apex, but 
chiefly to the 
recoil of heart 
and change in 
shape, for dur- 
ing the systole 
it becomes 
harder and 
more globular. 



TIME. 



TV 



CONDITION OF 
CIRCULATION. 



Contraction o f 
ventricles, f o 1- 
lowing that of 
auricles. Clos- 
ure of auriculo- 
ventricular 
valves, open aor- 
tic and pulmon- 
ary valves; pro- 
pulsion of blood 
into the arteries. 
Impulse of the 
heart immediate- 
ly followed by 
pulse at the 
wrist. 

Auricles dilating. 

Filling of both au- 
ricles and and 
ventricles. Clos- 
ure of arterial 
valves, opening 
of auriculo-ven- 
tricular valves. 

Complete disten- 
tion of auricles, 
followed by their 
contraction, and 
distention of 
ventricles. Au- 
riculo - ventricu- 
lar valves open, 
arterial valves 
closed. 



DISEASES OF THE CIRCULATORY SYSTEM. 
ENDOCARDIAL MURMURS. 



195 



TIME. 


situation. 


ORIFICE. 


NATURE. 


Systolic. 

Diastolic. 
Presystolic. 


Basic (right). 

" (left). 
Apical. 

Basic. 
Apical. 


Aortic. 

Pulmonary. 

Mitral. 

Tricuspid. 

Aortic. 

Mitral. 


Obstructive (stenosis). 
<< «< 

Regurgitant (insufficiency). 

<< <« 

<« << 
Obstructive (stenosis). 



Pulmonary regurgitant murmur (diastolic) and tricuspid obstructive 
murmur (presystolic) are very rarely met with clinically, and for all 
practical purposes they may be disregarded. 

The most frequent combinations of these murmurs are : — 

1. Combined aortic obstruction with regurgitation (systolic and dias- 
tolic murmur at right base). 

2. Mitral obstruction and regurgitation (presystolic and systolic api- 
cal murmur). 

3. Various combinations of the two preceding forms, the aortic 
and mitral valves being both diseased. 

4. Mitral obstruction with dilated right ventricle, and consequently 
tricuspid regurgitation (Dr. Aitken). (Systolic murmur heard best at 
lower part of sternum). 

Order of frequency of endocardial murmurs, commencing with the 
most common : — 



1. Mitral regurgitant. 

2. Aortic constrictive. 

3. Aortic regurgitant. 
4. 



Mitral constrictive. 



5. Tricuspid regurgitant. 

6. Pulmonary constrictive. 

7. Pulmonary regurgitant. 

8. Tricuspid constrictive. 



Order of relative gravity as " estimated not only by their ultimate 
lethal tendency, but by the amount of complicated miseries they in- 
flict."— Dr. Walshe: 



1. Tricuspid regurgitation. 

2. Mitral constriction and regur- 

gitation. 



3. Aortic regurgitation. 

4. Pulmonary constriction. 

5. Aortic constriction. 



I96 DIFFERENTIAL DIAGNOSIS. 

GENERAL RULES FOR THE DIAGNOSIS OF HEART 

DISEASE. 

Dr. John Hughes Bennett* gives the following rules : 

1. In health the cardiac dullness, on percussion, measures, immedi- 
ately below the nipple, two inches across, and the extent of dullness 
beyond this measurement commonly indicates either the increased size 
of the organ or undue distention of the pericardium. 

2. In health the apex of the heart may be felt and seen to strike the 
chest between the fifth and sixth ribs, a little below and a little to the 
inside of the left nipple. Any variations that may exist in the position 
of the apex are indications of disease, either of the heart itself or of 
the parts around it. 

3. A friction murmur synchronous with the heart's movements indi- 
cates pericardial or ex-pericardial exudation. 

4. A bellows murmur with the first sound, heard loudest over the 
apex, indicates mitral insufficiency. 

5. A bellows murmur with the second sound heard loudest at the 
base indicates aortic insufficiency. 

6. A bellows murmur with the second sound heard at the apex is 
rare. It indicates — 1st, aortic disease, the murmur being propagated 
downward to the apex; or 2d, roughened auricular surface of the mitral 
valves ; or 3d, mitral obstruction (pre-systolic murmur at apex). 

y. A murmur with the first sound loudest at the base, and propa- 
gated in the direction of the large arteries, is more common. It indi- 
cates — 1st, an altered condition of the blood, as in anaemia; or 2d, 
dilatation or disease of the aorta itself; or 3d, stricture of the aortic 
orifice, or disease of the aortic valve. 

8. Hypertrophy of the heart may exist independent of any valvular 
lesion, but this is rare. 

9. The pulse, as a general rule, is soft and irregular in mitral disease, 
but hard, jerking, or regular in aortic disease. 

10. Cerebral symptoms are more marked in aortic disease; pulmo- 
nary symptoms in mitral disease. 

Various constitutional symptoms should, in default of other obvious 

*" Lectures on the Principles and Practice of Medicine." 



DISEASES OF THE CIRCULATORY SYSTEM. 1 97 

causation, lead to the suspicion of disease of the heart. These are 
mainly : 

1. Symptoms referred to the circulation. Violent, continued pulsa- 
tion may arise from cardiac hypertrophy, and especially aortic regur- 
gitation. Cyanosis, blueness of the lips, coldness of the finger tips, 
etc., are common in many cardiac cases. Dropsy, commencing in lower 
extremities, is a late and dangerous symptom. 

2. Symptoms referred to the lungs. These are frequent cardiac com- 
plications, especially dyspnoea, orthopncea, and cough. 

3. Symptoms referred to the brain. Vertigo, languor, chorea, epi- 
lepsy, apoplexy, and paralysis may all be brought about by heart dis- 
ease. In sudden cerebral attacks in patients suffering with valvular 
disease, embolism is often at work. 

4. Stomach symptoms. Dyspepsia and hemorrhoids may find their 
origin in cardiac lesions. 

5. Throat symptoms. Pain in the throat is complained of in angina; 
hoarseness and aphonia sometimes attend pericarditis. 

6. Renal symptoms may follow heart disease. In all cases of cardiac 
disease the urine should be tested for albumen, as this condition may 
excite cardiac symptoms.* 

CLUBBING OF THE FINGER ENDS IN CHRONIC HEART 
DISEASE AND PHTHISIS. 

The following aphorisms on this point are laid down by Dr. Horace 

DOBELLlf 

Aphorism I. Clubbing of the finger ends on one or both sides of the 
body, with or without incurvations of the nails, may occur whenever 
the return of blood by one or both subclavian veins is seriously ob- 
structed for a considerable length of time. 

II. Symmetrical clubbing of the finger ends of both hands without 
incurvation of the sides and tips of the nails, is presumptive evidence 
of the existence of heart disease. 

III. Clubbing of the finger ends without incurvature of the sides 

*See also paper by Prof. DaCosta and Dr. Longstreth in Am. Journal for Medical 
Sciences, for July, 1880, for pathological relationship of heart disease and chronic kidney 
disorder. 

f " Affections of the Heart." London, 1876. 



1 98 



DIFFERENTIAL DIAGNOSIS. 



and tips of the nails is presumptive evidence against the existence of 
phthisis. 

IV. Symmetrical clubbing of the finger ends conjoined with incurv- 
ation of the sides and tips of the nails, is a sign that obstruction of the 
return blood by the subclavian veins and wasting of adipose tissue 
have co-existed. 

DIFFERENTIAL SIGNS BETWEEN ANAEMIC AND 
ORGANIC CARDIAC SOUNDS. 



ANEMIC SOUNDS. 

First sound heard over the right 
ventricle is distinct, second ring- 
ing; a soft systolic murmur is heard 
at left border of sternum. 

Sounds vary in character, at dif- 
ferent times, may disappear and re- 
appear. 

Sounds increase in intensity in 
following the aorta. 

Pressure with the stethoscope 
increases or develops the sound. 

Bruit du diable, a continuous 
musical hum, can be heard in the 
hollow above the right clavicle. 

Co-existence of pallor or anae- 
mia; amenorrhcea; leucorrhcea ; 
nervous exhaustion ; chorea; renal 
disease; phthisis. 



ORGANIC SOUNDS. 

Murmur generally harsh and 
blowing, and takes the place of one 
or both sounds of the heart. It 
may be distinctly located at apex 
or base. 

Sound the same after several ex- 
aminations. 

Sounds diminish in intensity in 
receding from the heart. 

Not affected by pressure. 

Not present (except when caused 
by pressure with the stethoscope). 

Co-existence of alteration in size 
of the heart; other organic signs; 
history of rheumatism. 



PAIN AT THE HEART. 
Pain is by no means a common symptom of heart disease. Not more 
than one in a dozen cases of chronic organic cardiac disease complain 
of pain at all.* In acute cardiac affections it is more frequent. In 
many cases of alleged pain at the heart, it will be found on examina- 
tion to proceed from indigestion, myalgia, intercostal neuralgia, en- 
larged spleen, mediastinal growth, pleurisy, or pericarditis. 

*Sansom, " Diagnosis of Diseases of the Heart," p. 3. 



DISEASES OF THE CIRCULATORY SYSTEM. 1 99 

APHORISMS OF DR. HORACE DOBELL. * 

I. Pain in the region of the heart and down the left arm does not 
necessarily indicate heart disease. 

It. The conjunction of pain in the region of the heart and pain in 
the left arm may be a most important symptom of heart disease, and 
is never to be disregarded. 

III. If pain is excited by exercise taken when the stomach is not 
distended with food or gas, and especially if it comes on quickly and 
increases steadily in severity with the continuance of exercise, it is al- 
most certain there is some serious disease of the circulatory organs. 

IV. When it is found that flatulence or a full meal embarrasses the 
heart painfully, a careful investigation should be made into the condi- 
tion both of the organ itself, and of the blood. 

V. Important heart disease may exist, and yet pain at the heart and 
in its neigborhood be absent. 

VI. The appalling import of pain in the throat in heart disease in- 
creases in proportion as the period of its onset deviates from the fol- 
lowing order of severity : — 

1. Pain under the left breast. 

2. Pain extending from under the left breast to mid-sternum. 

3. Pain extending from mid-sternum toward the left shoulder. 

4. Pain extending from the left shoulder down the left arm. 

5. Pain extending from mid-sternum toward the right shoulder. 

6. Pain extending from the left shoulder down the right arm. 

7. Pain extending up the sternum toward the region of the throat. 

8. Pain in the thyroid cartilage. 

When this order of advance is maintained as the exciting cause is 
continued, pain in the throat expresses the degree of dangerous per- 
sistence in the exciting cause of heart distress, rather than the de- 
gree of danger in the disease itself. 

VII. In proportion as the right side of the chest and right arm take 
precedence in the order of extension of pain at the heart and its neigh- 
borhood, the probability increases that the aorta is more diseased than 
the heart. 

* " On Affections of the Heart." London, 1876. 



200 



DIFFERENTIAL DIAGNOSIS. 



VIII. The volume of blood and other conditions being normal, the 
facility with which the pulse at the wrist is stopped by inspiration 
measures the loss of heart power. 

ANGINA PECTORIS. 

This disease is usually thought to be one typically connected with 
pain at the heart. This is by no means the case, as in many instances 
there is merely a sense of praecordial distress, but no actual pain (San- 
som). The diagnostic characters are : — 

1. The attacks are paroxysmal, coming on at varying intervals and 
duration (from a minute to an hour), without assignable cause. 

2. There is always a sensation of coldness experienced, and often a 
cold sweat. 

3. The heart's action is not increased, and may be diminished. 

4. The chest is fixed and breathing slow. 

5. The pain, when present, may be of great intensity, of a cold, 
sickening character, directly referred to the heart, with an accompany- 
ing sense of impending dissolution. 

Though essentially a neurosis, probably of the sympathetic (cardiac 
ganglia), angina pectoris is generally associated with some progressive 
degeneration of the muscular texture of the heart or coronary vessels. 

DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND 
AORTIC INCOMPETENCY. 



AORTIC OBSTRUCTION. 

Hypertrophy of left ven- 
tricle. 

To left. 

To left greatly. 



Forcible. 



Effect on Heart. 

Apex Displaced. 

Cardiac Dulness 
Increased. 

Character of Im- 
pulse. 



AORTIC INCOMPETENCY. 

Hypertrophy and dilata- 
tion of left ventricle. 

Downward and to left. 

Downward and to left, 
more increased than in 
obstruction. 

More forcible than in ob- 
struction, and over 
wider area. 



DISEASES OF THE CIRCULATORY SYSTEM. 



20 I 



DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND 
AORTIC INCOMPETENCY— {Continued). 



AORTIC OBSTRUCTION. 

To left of sternum. 

Onward, ventriculo-aor- 
tic. 

Systolic; loudest at be- 
ginning of systole. 

Right border of sternum, 
in second intercostal 
space. 

Upward to right sterno- 
clavicular articulation. 



Loud, harsh, or blowing. 



Murmur replaces first 
sound at base. 



Depends on condition of 
valves, but aortic sec- 
ond sound generally 
feeble. 

Systolic ; in second right 
intercostal space. 

Characteristic tracing 
with sphygmograph. 

Normal, or perhaps de- 
creased. 

Diminished. 



Impulse Felt. 

Murmur, its Di- 
rection. 



Time of 
mur. 



Mur- 



Point of Great- 
est Intensity, 

Direction in 
which Propa- 
gated. 

Character of 
Sound (very 
uncertain and 
of little value 
for diagnosis). 

Relation to Nor- 
mal Heart 
Sounds. 

Effect on Sec- 
ond Sound. 



Thrill. 



Effects 
Pulse. 



Frequency. 



Volume. 



o n 



AORTIC INCOMPETENCY. 



To left of sternum. 

Backward; aortic-ventri- 
cular. 

Diastolic ; post-systolic ; 
loudest at beginning 
of diastole. 

Right border of sternum, 
opposite third inter- 
costal space. 

Downward along ster- 
num and toward apex. 

Of higher pitch than in 
obstruction, and loud- 
ness decreases rapidly 
from commencement. 

Replaces second at base, 
and occupies more or 
less of the* pause. 

Apparent intensification 
of pulmonary second. 



Down sternum; diastolic. 

Visible pulsation in ar- 
teries (locomotive 
pulse). 

Normal, or perhaps de- 
creased. 

Increased. 



202 



DIFFERENTIAL DIAGNOSIS. 



DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND 
AORTIC INCOMPETENCY— {Continued). 



AORTIC OBSTRUCTION. 




AORTIC INCOMPETENCY. 


Diminished. 


Power. 


Increased. 


Regular. 


Rhythm. 


Regular. 


Slow. 


Duration. 


Quick. 


Arterial anaemia ; angina 
pectoris often present. 


General Ten- 
dency. 


As in obstruction, but 
sudden death more 
common than in any 
other form of valvular 
disease. 



DIFFERENTIAL SIGNS BETWEEN MITRAL OBSTRUC- 
TION AND MITRAL INCOMPETENCY. 



MITRAL OBSTRUCTION. 

Hypertrophy and dilata- 
tion of left auricle, and 
right chambers. 

To left and slightly 

downward. 
To right of sternum, also 

to left at base, greatly. 

Feeble, undulating, and 
diffused. 

To right of sternum and 
in epigastrium. 

Onward; auriculo-ven- 
tricular. 

Diastolic, presystolic, 
loudest at termination 
of diastole. 

A little within and up- 
ward from apex beat. 



Effect on Heart. 



Apex Displaced. 

Cardiac Dulness 
Increased. 



Character of Im- 
pulse. 

Impulse, where 
found ? 

Murmur, its Di- 
rection. 

Murmur, Time. 



Point of Great- 
est Intensity. 



MITRAL INCOMPETENCY. 



Hypertrophy and dilata- 
tion of all four cham- 
bers. 

To left and downward. 

To right of sternum, and 
also to left and down- 
ward. 

Even more deficient in 
force. 

Generally increased all 
over cardiac region. 

Backward ; ventriculo- 
auricular. 

Systolic, loudest at be- 
ginning of systole. 

A little outward and up- 
ward from apex beat. 



DISEASES OF THE CIRCULATORY SYSTEM. 



203 



DIFFERENTIAL SIGNS BETWEEN MITRAL OBSTRUCTION 
AND MITRAL INCOMPETENCY— {Continued). 



MITRAL OBSTRUCTION. 

Upward and inward to- 
ward right base. 

Generally rough and 
harsh. 



Precedes the first at apex, 
which is often very 
loud (presystolic.) 

Intensification of p u 1 - 
monary second. 

Presystolic ; upward and 
inward from apex. 

Increased. 
Diminished. 
Diminished greatly. 
Very irregular. 
Quick. 

Pulmonary and venous 
congestion and slow 
death by asphyxia. 



Direction in 
which Propa- 
gated. 

Character of 
Sound (very 
uncertain and 
of little value 
for diagnosis). 

Relation to Nor- 
mal Heart 
Sounds. 

Effect on Sec- 
ond Sound. 

Thrill. 



Effect on Pulse. 

Frequency. 

Volume. 

Power. 

Rhythm. 

Duration, 

General Ten- 
dency to 



MITRAL INCOMPETENCY. 



Upward toward left base, 
and backward into ax- 
illa, and behind. 

Blowing, bellows mur- 
mur. 



Replaces first at apex 
(systolic.) 

Intensification of p u 1 - 
monary second. 

At apex and toward ax- 
illa. 



Increased. 

Somewhat diminished. 

Diminished a little. 

Somewhat irregular. 

Nearly normal. 

As in obstruction, but 
there is more tendency 
to dropsy. Death by 
asthenia. 



DIFFERENTIAL SIGNS BETWEEN PULMONARY OB- 
STRUCTION AND TRICUSPID REGURGITATION. 



PULMONARY OBSTEUCTION. 

Systolic, onward, ventri- 
culo-pulmonary. 

Left border of sternum, 
in second interspace. 



Murmur. 

Point of Great- 
est Intensity. 



TRICUSPID REGURGI- 
TATION. 

Systolic, backward, ven- 
triculo-auricular. 

Base of ensiform carti- 
lage. 



204 



DIFFERENTIAL DIAGNOSIS. 



DIFFERENTIAL SIGNS BETWEEN PULMONARY OB- 
STRUCTION AND TRICUSPID REGURGITATION— 

{Continued). 



PULMONARY OBSTRUCTION. 

Generally anaemia. 
Sometimes pressure of 
solidified lung (phthi- 
sical or pneumonic) 
upon the artery. Rare- 
ly organic, and then 
usually congenital. 

Frequently bruit de dia- 
ble in the jugular veins. 




TRICUSPID REGURGI- 
TATION. 

Generally secondary to 
disease of the lung or 
of left side of the heart. 



Systolic pulsation of the 
distended j ugular veins. 



Endocardial murmurs can be distinguished from pericardial by at- 
tention to the following physical signs : — 



PERICARDITIS. 



STAGE. 



ist Stage. 

(Inflammation 
without e ffu - 
sion.) 



SYMPTOMS. 



If occurring during 
the course of acute 
rheumatism the dis- 
ease may come on 
insidiously. 

Pain and tenderness 
in the cardiac re- 
gion. Palpitation. 
Increased frequen- 
cy of thepulse. 
Shortness of breath. 
Anxiety. Pyrexia. 



PHYSICAL SIGNS. 



Greater extent of visible im- 
pulse than natural, and on 
palpation the impulse is 
found to be more forcible, 
but unequal. Friction fre- 
mitus rare. Area of dul- 
ness not altered. Single or 
double friction sound, often 
preceded by a cantering ac- 
tion of the heart.* Heart 
sounds may be unchanged 
or even louder than in 
health, or they may be 
masked by the friction 
sounds. 



* Cantering action of the heart, beside being met with in commencing pericarditis, is also 
caused by reduplication of the first or second sound of the heart against the thoracic wall 
at the moment of diastole, generally due to pericardial adhesions. 



DISEASES OF THE CIRCULATORY SYSTEM. 

PERICARDITIS— {Continued). 



205 



STAGE. 



2d Stage. 

(With effu- 
sion.) 



3d Stage. 
(Resolution.' 



SYMPTOMS. 



Less pain. Pulse 
small, frequent, and 
sometimes irregu- 
lar. Dyspnoea and 
o f t e n orthopnoea. 
Irritable cough. 
Loss of voice. Dys- 
phagia. Fullness of 
veins in the neck. 
Duskiness of com- 
plexion. Great 
anxiety. Sleepless- 
ness. Delirium. 



A gradual subsidence 
of the symptoms of 
the second stage. 



PHYSICAL SIGNS. 



Bulging of the precordial re- 
gion. Impulse displaced up- 
ward and outward; undu- 
latory. On palpation, feeble 
and sometimes not percep- 
tible; irregular. Area of 
cardiac dulness increased, 
first noticed at the base of 
the heart, and afterward ex- 
tending to left of apex beat, 
increased by the recumbent 
posture. Heart sounds fee- 
ble, distant, and muffled at 
apex, louder and more su- 
perficial at base. Friction 
may or may not be heard. 

Diminution of the dulness 
from above and laterally. 
Heart sounds become clear- 
er. Friction sounds may be 
heard With increased inten- 
sity. 



Post-mortem Appearances. — 1st. Pericardium is dry, inflamed and 
has lost its polish. Exudation of lymph on both surfaces, but more 
on the visceral. The membrane may have a shaggy appearance. 

2d. Fluid in variable quantity in the sac of the pericardium. Usually 
sero-fibrinous, containing flocculi of lymph. It may be purulent or 
bloody. 

3d. Organized lymph on the pericardium, with or without adhesions 
between the two surfaces, adherent or united by mesh-like adhesions. 

The Pain of Pericarditis. — Rheumatic pericarditis is more or less 
painful ; but secondary pericarditis developing in the acute stage of in- 
fectious or the chronic period of cachectic diseases, is invariably painless. 

Peripheric pain nearly equal on both sides of the chest ; or remaining 
localized at the precordial region, at the epigastrium, or at the leftside 



206 



DIFFERENTIAL DIAGNOSIS. 



of the xyphoid cartilage, does not increase the danger of the pericar- 
ditis. But if central, giving rise to disturbance of circulation and res- 
piration, and simulating that of angina pectoris, it means acute inflam- 
mation of the cardiac nerves, and marks ah exceptionally bad case of 
pericarditis. (Dr. Wertheimer, "These de Paris," 1876; Dobell's 
Reports.) 

DIAGNOSIS BETWEEN ACUTE ENDOCARDIAL AND EXO- 
CARDIAL (PERICARDIAL) SOUNDS. 
The sounds respectively perceptible in endocarditis and pericarditis 
and allied disorders, may be discriminated by the following table : — 



ENDOCARDIAL. 

I. A blowing sound, 



soft and 
bellows-like : not affected by pres- 
sure. 



2. A thrill may be felt on palpa- 
tion. 

3. The sound appears distant. 

4. May exist only with the sys- 
tole or the diastole. 



5. Accompanies 
sounds. 

6. Heard along 
the great vessels, 
round to the back. 



the heart 

the course of 
or conducted 



7. Persistent character. 



8. Area of cardiac dulness not 
altered. 



EXOCARDIAL. 

1. A creaking, rubbing, rough, 
to-and-fro sound, intensified by 
pressure of the stethoscope and by 
the patient bending forward. 

2. On palpation, friction fremitus 
may be felt. 

3. The sound appears near. 

4. Exists with diastole as well 
as systole. 

5. Does not correspond with the 
rhythm of the heart. 

6. Confined to the region of the 
heart and limited to site of pro- 
duction. 

7. Rapid and frequent change in 
character; here to-day and gone 
to-morrow. 

8. Increased area of dulness, if 
fluid be also present. 

DIFFERENTIAL SIGNS OF CARDIAC DILATATION AND 
PERICARDITIS WITH EFFUSION. 



CARDIAC DILATATION. 

Dulness increased in the hori- 
zontal axis, of a square outline. 



PERICARDITIS WITH EFFUSION. 

Precordial dulness extends up- 
ward, and is of a rounded pyra- 
midal outline, with apex above. 



DISEASES OF THE CIRCULATORY SYSTEM. 



207 



DIFFERENTIAL SIGNS OF CARDIAC DILATATION AND 
PERICARDITIS WITH EFFUSION— {Continued). 



CARDIAC DILATATION. 

Heart sounds feeble but clear. 



PERICARDITIS WITH EFFUSION. 

Heart sounds feeble, and distant 
sounding. 

Transition from dulness to lung 
resonance abrupt. 

Occasionally friction sound. 

Limits of dulness often vary 
from day to day or week to week. 

Apex beat some distance above 
lower limit of cardiac dulness. 

(Sansom.) 

There is no doubt but that the general rules laid down for detecting 
pericardial effusion have been too vague. Dr. T. M. Rotch, of Bos- 
ton, re-examined the subject, and succeeded in fixing a more perfect 
diagnostic sign than any hitherto mentioned. He shows that an area 
of flatness at from twp to three centimetres from the right edge of the 
sternum in the fifth intercostal space is almost absolutely sufficient to 
mark the presence of an effusion, and differentiate it from enlarged 
heart.* 



Transition from dulness to lung 
resonance more gradual. 

No friction sound. 

Limits of dulness persistent. 

Apex beat felt at lower limits of 
cardiac dulness; impulse diffused. 



DIFFERENTIAL SIGNS 



OF HYPERTROPHY AND DILA- 
TATION. 



Palpation. 



Percussion. 



SIMPLE HYPERTROPHY. 



Cardiac area ex- 
t ended. Im- 
pulse strong, 
lifting, or forc- 
ing. 

Dulness increased 
' laterally and 
downward. 



HYPERTROPHY 
"WITH DILATATION. 



Extent of visible 
impulse great- 
1 y increased. 
Action regu- 
lar, strong. 

Dulness lateral 
and down- 
ward. 



SIMPLE DILATATION. 



Extent of impulse 
greatly in- 
creased; but 
feeble, without 
lifting or forc- 
ing character. 

Dulness increased 
in the horizon- 
tal axis of the 
heart. 



* " Medical Communications of the Massachusetts Medical Society." 1878. 



208 



DIFFERENTIAL DIAGNOSIS. 



DIFFERENTIAL SIGNS OF HYPERTROPHY AND DILA- 
TATION— ( Continued). 





SIMPLE HYPERTROPHY. 


HYPERTROPHY 
WITH DILATATION. 


SIMPLE DILATATION. 


Auscultation. 


First sound dull, 


Both sounds pro- 


Both sounds 




prolonged, in- 


longed. 


short, abrupt, 




tensified ; sec- 




and feeble. Fee- 




ond sound in- 


. 


ble respiratory 




tensified. No re- 




murmur. 




spiratory mur- 








mur over prae- 








cordium. 






Pulse. 


Strong, full, in- 


Less strong, var- 


Weak, compressi- 




compressible. 


iable. 


ble, irregular. 


General symp- 


Fullness in the 




Dyspnoea, cough, 


toms. 


head, epigastric 




palpitation, por- 




weight, short 




tal congestion, 




breath, rare- 




debility, ascites. 




ly d e b i 1 i ty ; 








B righ t's dis- 


• 






ease. 







FATTY DEGENERATION OF THE HEART. 

This condition of the heart is frequently associated with dilatation. 
Generally the area of precordial dullness is normal or slightly in- 
creased; the impulse weak; the apex beat indistinct; the action irreg- 
ular ; the first sound short and feeble ; the second prolonged and in- 
tensified ; pulse is irregular. 

These physical signs obviously offer very little ground for a diag- 
nosis. Of rational signs the following have been mentioned : 

1. Attacks of faintness attended with sensations of great coldness, 
recurring without obvious cause. (Da Costa.) 

2. Arcus senilis. For this to be significant of cardiac degeneration, 
the ring must be ill-defined, rather yellowish than white, and the rest 
of the cornea be slightly cloudy or opaque, not clear and translucent, 
a tinge of jaundice being present. When this is the case, " the 
chances of cardiac degeneration are formidable." (Sansom.) 



DISEASES OF THE CIRCULATORY SYSTEM. 2O9 

3. Paroxysms of severe pain across the upper part of the sternum, 
and in the region of the heart. 

4. Stomach derangements, accompanied sometimes by constipation, 
but more generally by diarrhoea and frequent vomiting. This Dr. L. 
H. J. Hayne thinks " almost pathognomonic of this disease." (Lancet, 
January, 1875.) 

5. The " Cheyne-Stokes " respiration of ascending and descending 
rhythm is present in about one- third of the cases, and is probably de- 
pendent on atheroma of the aorta (Hayden). It also occurs in disease 
of the medulla oblongata. This symptom was first described in a 
case by Dr. Cheyne, in 18 18, as follows : 

" For several days his breathing was irregular ; it would entirely cease 
for a quarter of a minute; then it would become perceptible, though 
very slow ; then, by degrees, it became heaving and quick ; and then 
it would gradually cease again. This revolution in the state of 
breathing occupied about a minute, during which there were about 
thirty acts of respiration." In this case fatty disease of the heart was 
very marked, while the valves were healthy, and the aorta was 
" studded with steatomatous and earthy concretions." 

No general attention, however, was directed to the peculiarity and 
striking character of this symptom, until, in 1846, Dr. Stokes urged 
its significance as a sign of fatty degeneration of the heart, believing 
that its presence was pathognomonic of this affection, and that it 
always berokened a fatal and not far distant termination. That it did 
not necessarily depend on fatty degeneration of the heart itself, was 
soon shown by Dr. Seaton Reid, who described a case in which the 
muscular structure was healthy, while the mitral and aortic valves 
were both incompetent, the left ventricle was hypertrophied, and the 
aorta dilated and atheromatous. It remains an important and signifi- 
cant, if not a pathognomonic sign. 

Dr. Hayden is of opinion that the absence of the impulse, or its ex- 
tremely feeble character; the brief duration of the first sound, whether 
marked or sharp, in primary cases, and its almost complete or absolute 
extinction in those preceded by hypertrophy; the restriction of the 
sounds within a very limited area; and the occasional irregularity of 
the heart's action, will suffice, in the majority of cases, to establish the 
14 



210 DIFFERENTIAL DIAGNOSIS. 

diagnosis of fatty heart from the physical signs alone. He adds that 
the incipiency of primary Bitty degeneration may be suspected, if the 
pulse, previously regular, becomes weak and irregular; if the surface 
be pale, the patient subject to dizziness or syncope, and the cardiac 
impulse feeble; although the sounds of the heart may not apprec:^:.;.- 
difTer from their normal character. 

A slaw pulse sometimes is associated with fatty heart; but ft also oc- 
curs in yellow fever, dengue, jaundice, and as a result of disorders of the 
vagus nerve, and follows diphtheria; or comes after an attack of mala- 
rial fever; also as a result of the administration of certain drugs, such 
as digitalis or aconite. In all cases it is necessary to exclude a slow 
pulse which is natural and peculiar to the patient. Irregular or slow 
pulse due to adherent pericardium may be distingushed by the history 
and physical signs. 



CHAPTER IV. 

DISEASES OF THE DIGESTIVE SYSTEM. 

The Stomach and Bowels. — Principal Symptoms— The Tongue — The 
Appetite — Acidity (i) from Fermentation, (2) from Hypersecretion — 
Pain— Flatulence — Vertigo, (1) Stomachal, (2) Cerebral — Vomiting, 
(1) Stomachal, (2) Cerebral — Comparison of Atonic Dyspepsia, Chronic 
Gastritis, Gastric Ulcer and Gastric Cancer — Indigestion or Dyspep- 
sia — Abdominal Phthisis — Obstruction of the Bowels, Enteritis and 
Colitis. 

The Liver. — Method of Examination — Significance of Pain in the 
Liver — Significance of Jaundice— Jaundice with Obstruction— Jaun- 
dice without Obstruction — Diseases Characterized by Enlargement 
with Smooth Surface ; Enlargement with Uneven Surface ; with Di- 
minution of the Organ — Hepatic Abscess. 

Internal Parasites. — Tape-worm — Hydatids — Round Worms — 
Thread Worms — Trichinosis. 

The principal symptoms to which the attention is directed in the 
diagnosis of diseases of the digestive organs are those connected with 
the tongue, the appetite, pyrosis, vomiting, flatulence, vertigo and pain. 

THE TONGUE. 
Late writers have shown considerable skepticism on the accuracy of 
the appearance of the tongue as indicative of the condition of the 
lining membrane of the stomach. It is true that a white and furred 
or a red and cracked tongue is occasionally seen in healthy subjects ; 
but the standard of comparison should not be an ideally clean tongue, 
but the condition of the organ in the patient under inspection when in 
health. Local causes, such as carious teeth and irritating agents (to- 
bacco, tea, mercury, etc.), must be allowed for in the examination. 
When these and similar considerations are weighed together with the 
repeated instances of simultaneous affections of the stomach and tongue 

(211) 



212 DIFFERENTIAL DIAGNOSIS. 

revealed by post-mortems, no question remains that the appearance and 
state of the latter organ often is of high diagnostic worth. 

Dr. Robert Farquharson states, in a lecture on the diagnosis of 
dyspepsia, 514 that in his experience the class, of tongue which coincides 
most commonly with digestive disturbance is that in which the tongue 
seems to be covered with a thin, white fur, which on minute inspection 
is seen to be composed of a series of minute raised dots, and this 
usually coincides with pain immediately following meals. 

If the tongue is raw and nearly stripped of epithelium, with enlarged 
and prominent papillae, as we often see in phthisis, pain immediately 
after food and vomiting are usual symptoms, or large, red papillae may 
stand in bold relief through a pale coating, or the tongue may be sim- 
ply large and pale and flabby, as though too big for the mouth. 

Dr. Wilson Fox specifies the following conditions of the tongue as 
valuable aids to diagnosis in this class of diseases : — 

Dyspepsia with distinct atony of the stomach. The tongue broad, 
pale, and flabby, the papillae generally enlarged, more especially on the 
tip and edges. 

Dyspepsia from irritative causes. The tongue is redder than usual, 
often of a bright florid color, or even raw looking. It is often pointed 
at the tip, which, together with the sides, presents an extreme degree 
of injection, the papillae standing out as vivid red points. This form is 
often associated with aphthae, and is most common in scrofulous chil- 
dren and phthisical adults. 

Dyspepsia from excessive or hurried eating is apt to present a tongue 
uniformly covered throughout the greater part of its surface with a 
thick fur, whitish or brownish, with some degree of enlargement and 
redness of the papillae at the tip and edges. 

Neuroses of the stomach display a tongue which, as a rule, is clean, 
though often pale, broad and flabby. 

Superficial ulceration, or milk patches on the tongue occur in sec- 
ondary syphilis. Psoriasis and cancer of the tongue may be distin- 
guished by the appearance of the organ, and the presence of cachexia 
in the latter disease. 

* Medical Press and Circular, July, 1877. 



DISEASES OF THE DIGESTIVE SYSTEM. 



213 



THE APPETITE. 

Anorexia , or loss of appetite, is observed in cancer, in most inflamma- 
tory states of the stomach, in obstinate constipation, as well as in the 
pyrexial state. 

Boulimia, or excessive appetite, is found associated with enlargement 
of the stomach, induration of its coats, also in diabetes and various 
forms of mental alienation. 

Capricious or depraved appetite is met with in sufferers from intes- 
tinal worms, in some cases of chronic inflammation of the stomach, as 
well as in chlorosis, pregnancy and hysteria. 

ACIDITY OF THE STOMACH, (1) FROM FERMENTATION 
(2) FROM HYPER-SECRETION. 

Acidity of the stomach, pyrosis, heartburn, and water-brash, are dis- 
turbances of the digestion frequently included in one category. In all, 
an excessive amount of acid is formed in the stomach ; but in some 
cases the origin of the acid is to be sought in fermentative action, and 
in others in hyper-secretion from the coats of the stomach, thus calling 
for different lines of treatment. 

The following differential table, based on one given by Dr. Wilson 
Fox, exhibits in a concise form the distinction between the two forms 
of acidity: — 



ACIDITY FROM FERMEN- 
TATION. 
Occurs in connection with causes 
which impede digestion. 



Usually attains its height some 
hours after food, and is more 
marked in proportion to the size of 
the meal, and inversely to the di- 
gestive powers. 

Flatulence is common. 

Pain not severe, and but slightly 
or not at all relieved by eating. 



ACIDITY FROM HYPER- 
SECRETION. 

Is most common as a reflex 
symptom, or in connection with 
other nervous disturbance, or with 
ulcer and cancer of the stomach. 

Occurs in the empty stomach, 
or rapidly after food, and is often of 
great intensity after a small meal. 



Flatulence is rare. 

Pain more severe, most felt when 
the stomach is empty, and is re- 
lieved by food. 



214 



DIFFERENTIAL DIAGNOSIS. 



ACIDITY FROM FERMEN- 
TATION. 

Vomiting is rare. 

Vomited matters may contain 
organic acids, bacteria, torulae and 
sarcinae. 

Urine frequently shows an alka- 
line reaction. 



ACIDITY FROM HYPER- 
SECRETION. 

Vomiting is common. 

Vomited matters contain hydro- 
chloric acid in excess. 



Urine rarely alkaline. 



In both forms the process of digestion is impaired, but to a more 
marked degree in the fermentative variety, in which also, as a natural 
consequence, the impairment of nutrition of the patient is more ob- 
vious. As the fermentative action interferes with the functions of the 
liver, the stools are apt to be pale, and the patient suffer with consti- 
pation. The frequency with which attacks of gout and rheumatism 
are preceded by this form of acidity points to a diathetic process in- 
volving the general constitution. 

PAIN. 
Pain in the stomach is indicative of one of the following conditions : 

1. The presence of irritating foreign bodies, as mechanical sub- 
stances, corrosive poisons, blood or bile in large quantities, inflation 
from air or gases, etc. 

2. Organic diseases altering the anatomical structure of the coats, 
especially gastritis, chronic ulcer, cancer, and thickening of the pylorus. 

3. Perverted secretions, as in acidity. 

4. Perverted innervation, which may be a local visceral neurosis,* 
as in forms of dyspepsia where pain is the prominent symptom, or as 
in cramp of the muscles of the stomach; or it may be from general 
disorders, as in patients of a rheumatic or gouty diathesis; or it may 
be referable to the general nervous system, as in pure neuralgia of the 
stomach and hysteria. 

Pain in the stomach must be distinguished from rheumatic and other 
pains in the abdominal muscles immediately over the stomach. In 

* Clifford Albutt's lectures on the Visceral Neuroses (London, 1884), very pointedly calls 
attention to a class of disorders that are often mistaken for cancer, but, unlike this, are rarely 
fatal, and quite amenable to treatment.. 



DISEASES OF THE DIGESTIVE SYSTEM. 



215 



the latter the superficial tenderness is much greater; it is usually more 
marked in the left recti and obliqui abdominis muscles, and especially 
near their attachment to the ribs, where moderate pressure cannot af- 
fect the stomach, and by its independence of the digestive acts (Bric- 
quet). 

Pain in the stomach is also liable to be simulated by pain in the 
course of the transverse colon, especially when the colon is distended 
with gas. The diagnosis may usually be made by gentle percussion, 
the note arising from tapping a distended colon being less prolonged 
and of a higher pitch than that elicited from the stomach. The pain 
from the colon is also less felt at the ensiform cartilage than in the hy- 
pochondriac regions, and often extends toward the sigmoid flexure, 
and is associated with other signs of intestinal flatulence. 

Pain in the stomach depending on diseases of the spinal cord, is dis- 
tinguished by its superficial tenderness, by the presence of other pain- 
ful points in the affected nerves, and by the co-existence of other nerv- 
ous, and the absence of digestive, symptoms. 

Pain in the stomach may be simply neuralgic, or dependent upon 
gastric catarrh, or it may be due to organic lesions. The distinctive 
features between gastralgia and gastric ulcer are as follows :* — 



NERVOUS GASTRALGIA. 

Pain is often independent of the 
ingestion of food, and may even 
be relieved by taking food. 



often relieved by firm 



Pain is 
pressure. 

Pain is rarely relieved by vomit- 
ing. 

Fixed points of tenderness and 
of subjective pain not generally 
present. 

Relief is usually complete be- 
tween the paroxysms. 

Nutrition frequently well pre- 
served. 

* W. H. Welch, Pepper's System of Medicine, vol. ii, page 516 



ULCER OF THE STOMACH. 

Pain mostly dependent upon 
taking food, and its intensity varies 
with the quantity and the quality 
of the food. 

Pain is increased by pressure. 



Pain after a meal usually relieved 
by vomiting. 

These are often present. 



Some pain often continues be- 
tween the paroxysms. 

Nutrition usually affected. 



DIFFERENTIAL DIAGNOSIS. 



NERVOUS GASTRALGIA. 

Usually associated with other 
nervous affections, such as hysteria, 
neuralgia in other places, ovarian 
tenderness, etc. 

Benefited less by regulation of 
diet than by electricity and tonic 
treatment. 



Not followed 
the stomach. 



by dilatation of 



No local alteration of tempera- 
ture (Peter). 



ULCER OF THE STOMACH. 

Neuropathic states less con- 
stantly present. 



Benefited not by electricity, but 
by regulation of diet. 

Dilatation of the stomach may 
supervene. 

Surface temperature of epigas- 
trium elevated (Peter). 



FLATULENCE AND ERUCTATION. 

Dyspeptics generally suffer with gases in the stomach, producing 
eructations. These gases are either generated from imperfectly di- 
gested food or are derived from the capillaries. 

Eructations having the taste or odor of spoiled eggs, and occurring 
during the process of digestion, indicate the presence of sulphuretted 
hydrogen, from the decomposition of food. 

When the eructations are odorless, and occur chiefly in an empty 
state of the stomach, they indicate the escape from the blood of car- 
bonic acid, hydrogen or nitrogen, through the coats of the capillaries. 
(Oftener in hysterical subjects.) 

In the former case the indications are to use anti-ferments; while in 
the latter relief is often attained by simply regulating the hours of 
meals, so as to avoid long intervals between the times of taking food. 

GASTRIC VERTIGO. (VERTIGO E STOMACHO L^ESO.) 

Stomachal vertigo may be difficult to distinguish as such, because 
in all vertiginous attacks, the stomach is disturbed. In undoubted 
examples the vertigo always bears some distinct relation to the con- 
dition of the stomach, coming on only when that organ is full, or 
only when it is empty, or only after certain articles of food, as shell- 
fish, strawberries, coffee, fresh bread, etc. There are also generally 



DISEASES OF THE DIGESTIVE SYSTEM. 



21/ 



some dyspeptic symptoms other than vertigo complained of. Some 
other points are mentioned in the following table : — 



STOMACHAL VERTIGO. 

Usually appears in definite rela- 
tion to taking food; either after a 
meal, after particular ingesta, or on 
an empty stomach. 

Generally occurs in middle life. 

The apparent motion is felt to be 
subjective, not real (Gowers). 

Special senses not involved be- 
yond perverted vision. Conscious- 
ness never lost. 



CEREBRAL VERTIGO. 

Occurs without relation to the 
taking of food. 



Occurs in advanced life. 

A sense of movement or actual 
turning of objects. 

Deafness and tinnitus aurium 
often present. Sometimes loss of 
consciousness. 



VOMITING, (1) FROM DISEASE OF THE STOMACH, (2) 
FROM DISEASES OF THE BRAIN. 

Persistent vomiting is a frequent symptom of obstinate gastric dis- 
turbance ; and it has also been frequently noted as a symptom asso- 
ciated with organic diseases of the brain and cord, not unfrequently 
masking them and diverting the attention of the practitioner from the 
real seat of lesion. Thus in suddenly induced cerebral ansemia, in the 
commencement of the paralysis which follows diphtheria, in tubercu- 
lar meningitis, in concussion of the brain, in poisoning affecting the 
brain and cord, and in fact in almost any disease of the cerebral cen- 
tres, but especially the meninges, it is possible that one of the earlier 
and prominent symptoms will be obstinate vomiting. 

A comparison of the leading clinical features of these two forms 
shows that they may be readily distinguished. 

In a general way it may be stated that vomiting arising from the 
stomach is attended with more or less pain, with a furred tongue, with 
constipation or diarrhoea, sense of weight at the epigastrium, and pre- 
ceded for a considerable period by a sense of nausea. 

Vomiting from cerebral causes, on the other hand, is usually char- 
acterized by an absence of these symptoms, by a clean tongue, and a 
history of freedom from digestive disturbance. 



218 



DIFFERENTIAL DIAGNOSIS. 



Dr. Romberg has given the following criteria for its discrimination 
when the vomiting is of cerebral origin: 

1. The influence of the position of the head; the vomiting is ar- 
rested in the horizontal, and recurs and is frequently repeated in the 
erect position. 

2. The prevailing absence of premonitory nausea. 

3. The peculiar character of the act of vomiting; the contents of 
the stomach are ejected without fatigue or retching, as the milk is re- 
jected by babies at the breast. 

4. The complication with other phenomena, the more frequent of 
which are pains in the head, and irregularity of the cardiac and radial 
pulse, increased during and subsequent to the act of vomiting. 

The following differential table further exhibits the points of contrast 
(from Dr. W. Fox) : 



GASTRIC VOMITING. 

Epigastric pain and tenderness 
are common, and in some cases 
very marked. 

Nausea is constant. 

Oppression and weight at the 
epigastrium are constant. 

Bowels are variable. 

The tongue is loaded, except in 
certain cases of cancer or ulcer. 

Headache is absent, or not in- 
tense, chiefly frontal, of gradual 
invasion, and relieved by vomiting. 

Vertigo is rare and relieved by 
the vomiting. 

Other nervous phenomena are 
rarely present, and then only in 
slighter forms, and relieved by 
vomiting. 



CEREBRAL VOMITING. 

Epigastric tenderness and pain 
are rare. 

Nausea is frequently absent 
These are rare. 



Bowels are constipated. 
The tongue is usually clean. 

Headache often violent, the in- 
vasion sudden, and not relieved by 
vomiting. 

Vertigo is very frequent, and 
not relieved by the vomiting. 

Indistinctness of vision and 
diplopia. Confusion of ideas. Loss 
of memory. Not relieved by vom- 
iting. Anaesthesia or paresthesia, 
paralysis or cramp, convulsion or 
coma, are common or soon super- 
vene. 



DISEASES OF THE DIGESTIVE SYSTEM. 219 

The indications derived from the nature of the matters thrown up 
in vomiting are as follows : 

Ingesta. The food is returned unaltered, or but slightly changed, 
in nervous vomiting ; in a half digested state and strongly acid in 
chronic inflammation and cancer of the stomach; mixed with the mi- 
croscopic forms such as sarcinae and torulae in chronic gastritis, gas- 
tric ulcer, and cancer. 

Mucus is vomited in a catarrhal or sub-inflammatory condition of 
the stomach. 

Bile appears whenever the retching is long and violent, and does not 
indicate any special disease. 

Pus is not formed in the stomach, and when present in the vomit in- 
dicates disease in the oesophagus or air passages. 

Fceces also indicates a disease elsewhere than the stomach, usually 
an obstruction of the intestinal canal. 

Blood is vomited in gastric cancer and ulcer, in severe gastritis, 
in external injuries, vicariously (of the uterus), and frequently from 
disease of the heart or liver, producing distention of the capillaries. 
The presence of blood directly proceeding from the stomach, says Dr. 
Fox, if accompanied by severe pain, is almost pathognomonic of either 
gastric ulcer or cancer. 

CHRONIC GASTRITIS, GASTRIC ULCER, AND GASTRIC 

CANCER. 

The chief points in the diagnosis of diseases of the stomach are 
those connected with the differentiation of simple indigestion (atony 
of the stomach), inflammatory dyspepsia (gastritis, gastric catarrh, 
catarrhal inflammation of the stomach), gastric ulcer and gastric cancer. 

From this group the nervous disturbances of the stomach are 
broadly marked off by the superficial character of the pain in these 
latter, its independence of the acts of digestion and the nature of the 
food, the co-existence of other neuralgia, the frequent absence of 
emaciation and other disturbances of nutrition, and the sex and age of 
the patients. 

In reference to the value of percussion in the diagnosis of gastric 
cancer, Professor Peter, of Paris, has directed attention to the fact 
that wh<p superficial percussion is made over the epigastric region 



220 



DIFFERENTIAL DIAGNOSIS. 



somewhat distended by gas, there is found at certain points, especially 
in the region of the greater curvature, a certain obscurity* of the note 
alternating with the zones of sonority. But this sign is absolutely 
wanting on deep percussion such as is ordinarily employed. Prof. 
Peter, by this means, detected a cancer of the stomach situated at the 
posterior surface of the greater curvature, with some cancerous nod- 
ules probably disseminated through the epiploon below the splenic 
region and also in the hypogastric region. At this last point also su- 
perficial percussion gave the same results. 

An earl\- sign of gastric cancer is the presence of enlarged glands 
in the skin of the ?iavel (Maunder). To ascertain the mobility and 
outline of the stomach, the patient may be desired to drink one or two 
tumblers of soda water or a seidlitz powder. This distends the stom- 
ach and makes the tumor prominent. 

The following comparative table* will be found useful in distinguish- 



ing between the grave forms of stomach disorder: 



GASTRIC CANCER. 

Tumor present in three- 
fourths of the cases. 

■Rare under forty years of 
ase. 



GASTRIC ULCER. 
Tumor rare. 

May occur at any age after 
childhood ; one-half of cases 
under forty years. 

I;:;.:::: indefinite; 
be several years. 

Less frequent; often pro 
fuse; early. 



CHRONIC CATARRHAL 
GASTRITIS. 
No tumor. 

May occur at any age. 



mav Duration indefinite. 



Rare'y referable to dilata- 
tion, ana then only late in the 
disease. 

Free hydrochloric acid usu- 



Gastric hemorrhage rare. 



Vomiting mayor may r. :: 
be ~-. zi -.:.'. 

Free hydochloric acid may 



Average duration about one 
year ; rarely over two years. 

Hemorrhage frequent; 
rarely profuse ; most common 
in cachectic stage. 

Vomiting often has the pe- 
culiarities of that of dilata- 
tion of the stomach. 

Free hydrochloric acid usu- 
s.y absent from the gastric 
contents in cancerous dilata- 
tion of the stomach. 

Cancerous fragments may 
be found in the washings from 
the stomach" or in the vomit 
(rare). 

Secondary cancers may be 
recognized in . the liver, the 
peritoneum, the lymphatic 
glands, and rarely in other 
parts of the body. 

*W. H. Welch, Peppers System of Medicine, vol. ii., page 570. 



ally p:e;er.: 
contents. 

Absent. 



Absent. 



in the gastric be present or absent. 



A": sen:. 



Absent. 



DISEASES OF THE DIGESTIVE SYSTEM. 



22 



GASTRIC CANCER. 

Loss of flesh and strength, 
and development of cachexia 
usually more marked and 
rapid than in ulcer or gastri- 
tis, and less explicable by the 
gastric symptoms. 

Epigastric pain is often 
more continuous; less de- 
pendent upon taking food ; 
less relieved by vomiting and 
less localized than in ulcer. 

Causation not known. 



No improvement, or only 
temporary improvement in 
the course of the disease. 



GASTRIC ULCER. 



Cachectic appearances usu- 
ally less marked, and of later 
occurrence than in cancer, 
and more manifestly depend- 
ent upon the gastric disorders. 

Pain is often more parox- 
ysmal, more influenced by 
taking food, oftener relieved 
by vomiting, and more sharp- 
ly localized than in cancer. 

. Causation not known. 



Sometimes a history of one 
or more previous similar at- 
tacks. The coma may be ir- 
regular and intermittent. 
Usually marked improvement 
by regulation of diet. 



CHRONIC CATARRHAL 
GASTRITIS. 

When uncomplicated usu- 
ally no appearance of cach- 



The pain or distress in- 
duced by taking food is usu- 
ally less severe than in can- 
cer or in ulcer. Fixed point 
of tenderness usually absent. 

Often relerable to some 
known cause, such as abuse 
of alcohol, gormandizing, and 
certain diseases, such as 
phthisis, Bright's disease, cir- 
rhosis of the liver, etc. 

May be a history of pre- 
vious similar attacks. More 
amenable to regulation of diet 
than is cancer. 



INDIGESTION AND DYSPEPSIA. 

Although the distinction is not generally drawn in ordinary language 
between dyspepsia and indigestion, it should not be forgotten that they 
are not synonymous. Dyspepsia has reference to an altered condition 
of the digestive fluid, its deficiency or excess, or to an organic affection 
of the muscular walls of the stomach, which has for its result imper- 
fect or difficult chymification of the food; indigestion merely expresses 
a disturbance of function, and refers to the result rather than the cause. 
In dyspepsia the peptic glands or muscular apparatus of the stomach 
are defective, in indigestion they may be normal, but have their func- 
tions interfered with by improper and unaccustomed articles of food, 
or by reflex influence from other organs. 

The symptoms of INDIGESTION are tabulated by Dr. Murchi- 
son as follows * : — 



*" Functional Derangements of the Liver." London, 1874. 



222 



DIFFERENTIAL DIAGNOSIS. 



i. A feeling of weight and fulness at the epigastrium and in the 
region of the liver. 

2. Flatulent distention of the stomach and bowels. 

3. Heartburn and acid eructations. 

4. A -feeling of oppression, and often of weariness and aching pains 
in the limbs, or of insurmountable sleepiness after meals. 

5. A furred tongue, which is often indented at the edges, and a 
clammy, bitter, metallic taste in the mouth, especially in the morning, 

6. Appetite often good ; at other times anorexia and nausea. 

7. An excessive secretion of viscid mucus in the fauces, and at the 
back of the nose. 

8. Constipation, the motions being scybalous, sometimes too dark, 
at others too light, or even clay-colored. Occasionally attacks of 
diarrhoea, alternating with constipation, especially if the patient be in- 
temperate in the use of alcohol. 

9. In some patients attacks of palpitation of the heart, or irregular- 
ity or intermission of the pulse. 

10. In many patients occasional attacks of frontal headache. 

11. In many, restlessness at night and bad dreams. 

12. In some, attacks of vertigo and dimness of sight, often induced 
by particular articles of diet. 

DYSPEPSIA may be due to impaired motion as well as to deficient 
secretion. The following table will give the distinctive points for 
diagnosis : * 



Uneasiness after meals 



Flatulence 



1. Dyspepsia from im- 
paired motion. 

Constant symptom, generally 
soon replaced by sense of 
tension accompanying flatu- 
lency. 

Characteristic symptom. 



2. Dyspepsia from defec- 
tive SECRETION. 

Not infrequent, but commonly 
soon merged into acute pain. 



Comparatively infrequent ; some 
of the worst cases, in which 
pain after food and other symp- 
toms are particularly severe, 
are entirely free from flatus. 
The tendency is to lactic, buty- 
ric, and perhaps other forms of 
fermentation, in which gases 
are not evolved. 



* Arthur Leared. "Dyspepsia." British Medical Journal, May, 1879. p. 660. 



DISEASES OF THE DIGESTIVE SYSTEM. 



223 





I, Dyspepsia from im- 


2. Dyspepsia from defec- 




paired MOTION. 


tive SECRETION. 


Gastric pain 


Infrequent, but occurs occa- 


Variously described as sharp, 




sionally, as a result of flatu- 


shooting, dull, or dragging ; is 




lence, and is peculiar in 


the most characteristic symp- 




kind. 


tom of defective secretion of 
gastric juice. 


Constipation. -. . . . . 


Almost always a marked 


Not generally present, and the 




symptom. 


bowels are in many cases re- 
laxed. 


Treatment 


Strychnia, carbolic acid, thy- 


Diet, tonics, pepsin, acids, hygi- 




mol, charcoal. 


enic treatment. 



Hyperperistalsis, dyspepsia of fluids, flaccid stomach, and other 
states, give rise to similar symptoms. 

Clifford Albutt criticises the term dyspepsia, and urges the sub- 
stitution, in each case, of an exact term which shall correspond with 
the pathology of the disorder. 

ABDOMINAL PHTHISIS. 

Abdominal phthisis (tubercular peritonitis), in its acute forms, closely 
simulates typhoid fever. There are febrile symptoms attended with 
remissions, heat and dryness of the surface, pains in the limbs, drow- 
siness and disordered secretions, diarrhoea, and emaciation. It differs 
from typhoid in these particulars : — 

L. The pain is diffused over the abdomen, not limited to the caecal 
region. 

2. There are no red spots (with rare exceptions). When they occur 
they do not come out in crops, and are more papular and less erythe- 
matous. 

3. There is generally tubercular disease in other organs. 

4. The temperature may be irregularly febrile, but has not the morn- 
ing remissions, and does not pursue the typical cycle of that of typhoid 
fever. 

OBSTRUCTION OF THE BOWELS. 
The causes of a mechanical stoppage of the bowels are principally 
the following: Intussusception; impaction of faeces; strictures, often 
syphilitic or cancerous; twisting of the bowel (volvulus); herniae; 
pressure of tumors, and foreign bodies, such as gall-stone. 



224 DIFFERENTIAL DIAGNOSIS. 

The symptom first noticed is constipation with colicky pains, which 
do not yield to ordinary remedies ; slight distention of the abdomen, 
and some soreness on pressure. Vomiting follows, very severe, even 
becoming fecal. It is liable to be confounded with peritonitis and 
strangulated hernia. The following rules for diagnosis have been laid 
down by the eminent surgeon, Mr. Jonathan Hutchinson, of London : 

1. When a child becomes suddenly the subject of symptoms of 
bowel obstruction, it is probably either intussusception or peritonitis. 

2. When an elderly person is the patient, the diagnosis will generally 
rest between impaction of intestinal contents and malignant disease 
(stricture or tumor). 

3. In middle age the causes of obstruction may be various ; but in- 
tussusception and malignant disease, both of them common at the ex- 
tremes, are now very unusual. 

4. Intussusception cases may be known by the frequent straining, 
the passage of blood and mucus, the incompleteness of the constipa- 
tion, and the discovery of a sausage-like tumor, either by examination 
per anum or through the abdominal walls. 

5. In intussusception, the parietes usually remain lax, and, there 
being but little tympanites, it is almost always possible, without much 
difficulty, to discover the lump (or sausage-like tumor) by manipula- 
tion under ether. 

6. Malignant stricture may be suspected when, in an old person, 
continued abdominal uneasiness and repeated attacks of temporary 
constipation have preceded the illness. It is to be noted also that the 
constipation is often not complete. 

7. If a tumor be present and pressing on the bowel, it ought to be 
discoverable by palpation, under ether, through the abdominal walls, 
or by examination by the anus or vagina, great care being taken not 
to be misled by scybalous masses. 

8. If repeated attacks of dangerous obstruction have occurred with 
long intervals of perfect health, it may be suspected that the patient is 
the subject of a congenital diverticulum, or has bands of adhesion, or 
that some part of the intestine is pouched and liable to twist. 

9. If, in the early part of a case, the abdomen become distended and 
hard, it is almost certain that there is peritonitis. 



DISEASES OF THE DIGESTIVE SYSTEM. 225 

10. If the intestines continue to roll about visibly, it is almost cer- 
tain that there is no peritonitis. This symptom occurs chiefly in 
emaciated subjects, with obstruction in the colon of long duration. 

11. The tendency to vomit will usually be relative with three condi- 
tions and proportionate to them. These are (i) the nearness of the 
impediment to the stomach, (2) the tightness of the constriction, and 
(3) the persistence or otherwise with which food and medicine have 
been given by the mouth. 

12. In case of obstruction in the colon or rectum, sickness is often 
wholly absent. 

13. Violent retching and bile vomiting are often more troublesome 
in cases of gall-stones or renal calculus simulating obstruction than in 
true conditions of the latter. 

14. Fecal vomiting can occur only when the obstruction is moder- 
ately low down. If it happen early in the case, it is a most serious 
symptom, as implying tightness of constriction. 

15. The introduction of the fingers or entire hand into the rectum, 
for purposes of exploration, as recommended by Prof. Simon, of Kiel, 
may often furnish useful information. 

INFLAMMATORY DIARRHCEA (ENTERITIS), DYSEN- 
TERY (COLITIS), AND ENTERO-COLITIS. 

These diseases, both alike in being inflammations of the mucous 
membrane of the intestinal tract, are frequently associated. But for 
therapeutic as well as prognostic purposes, it is desirable to recognize 
the distinctions which they present in well marked types. They are : 



ENTERITIS. 

Seat of inflammation is in the 
small intestine. 

Usually begins with colic, nau- 
sea and vomiting, constipation 
(rarely diarrhcea), chilliness soon 
followed by high fever, thirst, and 
hot skin. 

Pulse at first tense and full ; soon 
becomes small, wiry, quick. 

15 



DYSENTERY. 

Seat of inflammation is in the 
large intestine. 

Usually begins with painless, 
slight diarrhcea, followed by chill, 
slight or no fever, sense of weight 
near the anus. No colic. 

Pulse often a little excited ; or if 
fever is high, full and rapid. 



226 DIFFERENTIAL DIAGNOSIS. 

ENTERITIS. I DYSENTERY. 

Pain paroxysmal, local tender- j Pain more moderate, usually dis- 
ness marked, greatly increased by | tinctly over the colon; moderate 
pressure. t I tenderness. 

Stools mucous, rarely blood, | Stools scanty, bloody, contain 
very rarely pus. No scybala. No | pus, scybala, little faeces. Marked 
tenesmus. tenesmus. 

Aortic pulsation felt by the pa- 1 Aortic pulsation not noticed by 
tient on the right of the umbilicus. I the patient. 

Entero-colitis is very common in early childhood; it is distin- 
guished from cholera infantum by its inflammatory character, gradual 
onset, and progressive character of symptoms, and amenability to 
treatment, especially hygienic and dietetic. 

DISEASES OF THE LIVER. 

Previous to an examination of the liver, the patient should have a 
free action of the bowels, as faecal accumulations are a constant cause 
of diagnostic errors. He should lie on his back on a firm bed, with 
his knees drawn up and the abdominal muscles relaxed. Palpation 
should be upon the patient's skin directly, not on the clothing. The 
physician, seating himself at the patient's right side, should apply the 
tips of the fingers of the right hand just below the free border of the 
ribs, and request the patient to make full inspiration and expiration. 
He will thus be able to feel the upper edge and surface of the liver 
and ascertain the condition of the surface, whether smooth or nodular. 
By percussion, which should be made while the patient is in the same 
position, the size of the liver can be quite accurately mapped out. 

These two facts are the first steps to a diagnosis ; as most hepatic 
diseases can be assigned to one of these classes : 

i. Liver enlarged, with smooth surface. 

2. Liver enlarged, with nodular surface. 

3. Liver atrophied. 

Pain in the hepatic region should be investigated ; whether dull or 
acute, persistent or intermittent, etc. The condition of jaundice is as- 
certained, in light cases, by examining the under surface of the tongue 



DISEASES OF THE DIGESTIVE SYSTEM. 227 

and the conjunctiva of the eye, which will display the icteric discolor- 
ation when the general surface does not A still more delicate test 
of the presence of jaundice is derivable from examination of the 
urine. The following three tests are employed by Prof. Hardy, of Paris : 

1. Chloroform. When this is poured upon normal urine it sinks, by 
reason of its great density, to the bottom of the test-glass, exhibiting 
there a crystalline transparency. If we pour it on the icteric urine, 
and having shaken the test-tube plugged by the thumb; leave it quiet 
for a moment, the chloroform deposit contrasts strongly by its dull 
color with the yellow of the superficial layers — the yellow color being 
deeper in proportion to the quantity of bile in the urine. It is an ex- 
cellent test of icteric urine. 

2. Iodine. When the tincture of iodine is poured upon the icteric 
urine the mixture must not be shaken. At the upper part of the tube 
three very distinct colors are observable — the first layer formed by the 
tincture is violet; below this is a kind of diaphragm of sea-green 
color; and the third layer, consisting of the urine, and occupying the 
lowest part, is yellow. 

3. Nitric Acid. When this agent has been poured in, the mixture, 
after shaking, assumes a bottle-green color passing into an olive. This 
is an entirely special and very characteristic appearance.* 

Masset recommends the following test: The urine to be examined 
should be acidulated with two or three drops of concentrated sulphuric 
acid, and a small crystal of potassium nitrate dropped into the mixture 
in a test tube. A bright grass-green color will be immediately pro- 
duced if the quantity of biliary coloring matter is large. Normal 
urine will, under the same circumstances, present a light rose-color by 
transmitted light. 

With these hepatic symptoms determined, a study of the following 
tables will in most instances readily supply a correct diagnosis. 

THE SIGNIFICANCE OF PAIN IN THE LIVER. 
Pain having its source in the liver is divided by Dr. Charles Mur- 
CHisoNf into three varieties, each of diagnostic significance: — 

* Revue de Therapeutique, August, 1 878. 
-j- " Lectures on Diseases of the Liver." 



228 DIFFERENTIAL DIAGNOSIS. 



CHARACTER OF PAIN. 
I. Pain severe, paroxysmal, with 



DISEASES FOUND IN. 
Obstruction of the bile duct by- 



distinct intermissions; little or no i gall-stones, etc. (hepatic colic); 
local tenderness; no fever; often j hepatic neuralgia (when jaundice 
associated with jaundice. is absent, probably the latter). 

II. Pain moderate, continuous, | Congestion and commencing in- 
slightly increased by pressure, often flammation of the organ; catarrh 



associated with pain in the right 
shoulder, slight febrile symptoms 
and jaundice. 

III. Pain severe, constant, great- 
ly increased by pressure, motion 



and partial obstruction of the bile 
ducts; acute atrophy. 

Always indicates inflammation 
of the capsule (peri-hepatitis), 



coughing, etc. More or less fever; which may supervene in various 
perhaps jaundice. j diseases (cirrhosis, hydatids, etc.). 

Hepatic pain may be simulated by various other conditions. The 
principal ones, with their characteristic differences, are as follows : — 

1. Pleurodynia. The pain is strictly localized to a small spot. Ab- 
sence of hepatic disturbance. 

2. Intercostal Neuralgia. Tender points along the course of the in- 
tercostal nerve. Chiefly referred to three points in the course of the 
nerve: (i) The vertebral groove; (2) The axillary region; (3) The 
termination of the nerve in front. Co-existence of neuralgia else- 
where. Absence of hepatic symptoms. Herpes zoster will occasion 
no difficulty if the patient be examined with his clothing removed. 

3. Pleurisy. Presence of pyrexia and physical signs of the disease. 

4. Gastrodynia. Comes on with relation to food (stomach always 
either full or empty). Pyrosis. 

5. Intestinal Colic. Pain referred to the umbilical region. No jaun- 
dice. Blue line of lead poisoning. Errors of diet. 

6. Renal Colic. Pain chiefly referred to one kidney, when it shoots 
to the testicle and down the thigh. No jaundice. Haematuria and 
renal calculus. 

Little or no hepatic pain is felt in — 

1. The waxy, lardaceous, or amyloid liver. 

2. The fatty liver. 

3. Simple hepatic hypertrophy. 

4. Hydatid tumor. 



DISEASES OF THE DIGESTIVE SYSTEM. 



229 



THE SIGNIFICANCE OF JAUNDICE. 
The common and obvious symptom of jaundice results either (1) 
from obstructions of the common bile duct; or (2) independently of any 
obstruction of the duct. The diagnosis of these two conditions may 
be presented as follows : — 



JAUNDICE FROM OBSTRUC- 
TION. 

When persistent, speedily be- 
comes intense. 

The stools are clay-colored. 

Tumor in the region of the gall- 
bladder often present. 

May appear suddenly in a per- 
son in good health. 

Intermittent jaundice in ad- 
vanced life signifies gall-stones. 

Pain usually in severe parox- 
ysms. 

Co-existence of ascites, preg- 
nancy, pyloric cancer (obstruction 
from without). 



JAUNDICE WITHOUT OB- 
STRUCTION. 

Persists and continues slight. 



The stools are natural. 
No tumor there. 

Appears gradually, unless there 
is a history of shock. 

Intermittent jaundice in youth 
signifies catarrh of the duodenum. 

Pain usually more or less con- 
stant. 

Preceding severe mental emo- 
tion, hepatic congestion, pyaemia, 
malarial fevers, phosphorus poison- 
ing, epidemic prevalence, acute 
atrophy of liver, cancer, etc. 



The principal diseases which are associated with these varieties of 
jaundice are the following : 

JAUNDICE FROM OBSTRUCTION MAY BE DUE TO 



DISEASES. 



i. Gall Stones. 



DIAGNOSIS. 



Biliary colic present. Pain acute, parox- 
ysmal, referred to the gall-bladder, and from 
this around to the right scapula. Tenderness 
absent or slight. Irregular rigors. No fever. 
Severe vomiting. Jaundice appears after a 
day or two. Pathognomonic sign ; the pres- 
ence of gall-stones in faeces. 



230 



DIFFERENTIAL DIAGNOSIS. 



JAUNDICE FROM OBSTRUCTION MAY BE DUE TO- 

{Continued.) 



DIAGNOSIS. 



2. Hydatids. 



3. Cancer and Tumors. 



Liver enlarged and altered in form but 
painless. Biliary colic with fever, quick pulse 

and high temperature. Pathognomonic : hy- 
datid vesicles in the faeces. Peculiar thrill. 

Antecedent history of visceral cancerous 
disease. Pain and nausea after taking food. 
A hard and sensitive tumor in the epigastric 
or right hypochondriac region. Hemorrhage 
from the stomach or bowels. Pains at night. 



JAUNDICE WITHOUT OBSTRUCTION MAY BE DUE TO 



DISEASE. 



1 :.-.:-:■" 515. 



1. Malarial Fevers. 

Yellow Fever, Py 
aemia. 

2. Epidemic Jaundice. 



3. Nervous Jaundice. 



Jaundice from Con- 
gestion. 



History of malarial or specific poisoning, 
or actual presence of one of the diseases 
named. 

Gastric catarrh ; stools pale ; epigastric 
soreness ; nausea or vomiting ; loss of appe- 
tite ; often commences with a chill after ex- 
posure. Most epidemics of jaundice seem to 
have been due to malarious poison or vitiated 
atmosphere. Infantile jaundice is of the lat- 
ter character. 

History of severe mental emotion, great 
suffering or sudden shock. Onset rapid ; 
often cerebral symptoms. 

Feeling of weight and soreness over liver. 
Bad breath ; poor appetite ; furred tongue ; 
vertigo. Right decubitus. Urine scantv and 
high colored. Slight dyspnoea. Bowels 
sluggish. 



Acute atrophy, mineral poisons ^especially by phosphorus), typhoid 
fever and very obstinate constipation, are other occasional causes of 
this form of jaundice. 



DISEASES OF THE DIGESTIVE SYSTEM. 



23I 



CLASSIFICATION OF HEPATIC DISEASES WITH RE- 
GARD TO THE SIZE OF THE LIVER.* 



I. LIVER 

Simple Hyperplasia. 

Leukemic Hyper- 
plasia. 



Congestion. 
(a) Simple. 



(b) From cardiac dis- 
ease. 



V) From malaria. 



Waxy Degeneration. 



Fatty Dengeneration. 



Hydatid Tumors. 



enlarged, surface smooth. 

Liver enlarged, smooth, painless ; absence 
of other symptoms. 

Liver enlarged and smooth. Spleen en- 
larged. Pallor of the skin. Pathognomonic; 
presence of a marked increase of the white 
blood globules, (1:20 arid upward.) 

Enlargement moderate. Tenderness ; con- 
junctiva jaundiced ; stools pale; bowels ir- 
regular; tongue coated; low spirits; head- 
ache; vertigo; noises in the ears. No jaun- 
dice or dropsy. 

Liver enlarged, smooth. Slight jaundice. 
Some dyspnoea. Dropsical effusions. Mitral 
or aortic disease. Emphysema or induration 
of the lungs. 

Enlargement slight. Enlarged spleen. 
History of malarial disease. Pathognomonic; 
the malarial pigment in the blood. 

Enlargement considerable, uniform, of slow 
growth, borders sharply defined, feel firm. 
Pain slight. Patient emaciated and cachec- 
tic. Splenic enlargement common. Diar- 
rhoea and dyspepsia. History of phthisis, 
syphilis, or protracted suppuration. 

Enlargement considerable, borders round- 
ed, feel doughy. No tenderness nor pain, 
spleen small; jaundice slight or absent. Diar- 
rhoea. A pale, smooth, greasy skin. History 
of intemperance, phthisis, or indolent life. 

Enlargement considerable, irregular, pain- 
less; usually of the left lobe of the organ. 
Feel elastic or fluctuating. Jaundice rare. 
Increase of size slow. No constitutional 
symptoms. 



* Partly taken from E. J. Janeway, " Diagnosis of Hepatic Affections," N. Y., 1877. 



232 



DIFFERENTIAL DIAGNOSIS. 



Acute 

PHY. 



Yellow Atro- 



CLASSIFICATION OF HEPATIC DISEASES WITH REGARD 
TO THE SIZE OF THE LIVER. 

I. LIVER ENLARGED, SURFACE SMOOTH {Continued). 

Simple Atrophy. Liver small, surface even. Preceded by 

ascites, dyspnoea, serious disease of heart or 
lungs, or signs of congestion. 

Rare. Jaundice always present, though 
rarely intense. Pain considerable. Tender- 
ness. Generally vomiting ; splenic dulness. 
Pulse irregular. The typhoid state common. 
Urine dark, acid, sp. grav. i. 012- 1.024; ab- 
sence of urea, uric acid and the chlorides ; 
presence of leucine and tyrosine (pathogno- 
monic). Intestinal hemorrhage and haema- 
temesis common. 

II. LIVER ENLARGED, SURFACE NODULAR OR IRREGULAR. 



Abscess or 
Hepatitis. 



Cancer. 



Tropical 



Syphilitic Liver. 



Liver enlarged, irregular surface bulging. 
Dull, heavy pain. Jaundice rare. Pyrexia 
and chills. History of residence in a warm 
climate. 

Enlargement often very great, progressive, 
irregular ; nodular excrescences often to be 
felt. Feel hard and resistant. Pain lancin- 
ating and tenderness acute. No febrile symp- 
toms. Jaundice. "The co-existence of en- 
larged liver with persistent jaundice ought 
always to raise the suspicion of cancer " 
(Murchison). Dyspepsia, nausea, vomiting, 
constipation, or diarrhoea, short, dry cough, 
ascites. Patients over 40. In suspected can- 
cer of the liver the urine should always be 
examined; half a drachm of strong nitric 
acid should be added to half an ounce of the 
urine. If the fluid changes to a dark or black 
hue, and especially if no albumen is present, 
and the liver is either increased or diminished 
in size, the diagnosis of melanotic cancer is 
rendered very probable. (Dr. Eiselt, of 
Prague.) 

Liver enlarged, surface nodulated, lobes 
irregular, separated by deep fissures. 



DISEASES OF THE DIGESTIVE SYSTEM. 233 

CLASSIFICATION OF HEPATIC DISEASES WITH REGARD 
TO THE SIZE OF THE LIVER— {Continued). 

III. LIVER DIMINISHED IN SIZE. 



Cirrhosis, or Chronic 
Atrophy. 



Liver small, sometimes only half size, sur- 
face granular or nodulated; "hob-nail liver." 
Outset insidious, with signs of disordered 
digestion. Dull pain and slight tenderness 
in hepatic region. Ascites common. Spleen 
often enlarged. Superficial veins of the ab- 
domen enlarged. Hemorrhoids frequent. 
Jaundice rare or slight. Progressive emacia- 
tion and debility. History of spirit- drinking 
almost invariably. 

HEPATIC ABSCESS. 

It has been shown* that an obscure and chronic form of hepatic 
abscess is a far more common disease than is generally supposed, and 
that it is often exceedingly difficult of diagnosis. 

These abscesses may exist without any local symptoms or such gen- 
eral disturbance of the system as is commonly regarded as indicating 
their presence, and are a very common concomitant of prolonged ma- 
larial poisoning. The pathognomonic sign of their presence is the 
discovery of pus on inspiration of the parenchyma of the liver. The 
place of election is one of the intercostal spaces. The rational symp- 
toms may be collated as as follows : — 

1. Gastric and intestinal derangements; dyspeptic symptoms of var- 
ious kinds. 

2. Slight jaundice, conjunctivae yellow; complexion sallow. 

3. Depression of spirits, hypochondria or melancholy. This is a 
very usual symptom, and so important that Dr. Hammond recommends 
that in all cases of hypochondria or melancholia the region of the 
liver should be carefully explored, and even if no fluctuation be de- 
tected, or any other sign of abscess be discovered, aspiration, with 

* Tauscky, Med. Record, April 20th, 1878; Hammond, St. Louis Clin. Record, June, 
1878; Byrd, N. Y. Med. Journal, July, 1878, etc. 



234 



DIFFERENTIAL DIAGNOSIS. 



proper precautions, should be performed. If pus be evacuated, the 
operation may be expected to be followed by a cure of the mental dis- 
order, as well as by the preservation of the life of the patient from the 
probably fatal conseqaences of hepatic abscess. 

4. Sense of weight or pain in the right side ; more or less tender- 
ness on pressure (all local symptoms often absent). 

5. Circumscribed fluctuation over the hepatic region. This is a pos- 
itive sign, but is by no means always to be discovered. 

6. Cerebral symptoms, as vertigo, cephalalgia, insomnia, hysteria, 
and hyperaemia. 

7. Slight rigors, and feverishness, simulating some of the more 
chronic forms of intermittent fever. 



INTESTINAL WORMS. 

The symptoms to which parasites in the intestinal canal and other 
organs give rise are numerous, but by no means specific or definite. 
The following tabular arrangement sets forth the more prominent: 



Tape Worm. 
' Taenia Solium. 
Taenia Saginata. 



Hydatid Cysts. 
Taenia Echinococci. 



Pain and discomfort in the belly; variable 
appetite ; constipation and diarrhoea alternat- 
ing; itching at the nose or anus without local 
cause ; low 6pirits, loss of flesh, nervous 
seizures. Stools variable. 

Pathognomonic : The discovery of scolices 
or joints in the stools, or about the anus, or 
of eggs in the faeces (microscopic). 

These occur chiefly in the lungs and liver. 
(See Diseases of the Liver.) They begin with 
a rounded, tense, smooth, elastic swelling, 
painless until inflammation begins, and with- 
out other symptoms than those caused by 
their size. They are often attended with the 
" hydatid thrill." This may be felt by plac- 
ing the left hand flat and closely upon the 
tumor, then percussing sharply with the fin- 
gers of the right hand. A long sustained 
tremor is observed, " like that experienced 
on an iron railway bridge during the passage 
of a train." 



DISEASES OF THE DIGESTIVE SYSTEM. 



235 



Hydatid Cysts {Contin- 
ued). 

Round Worms, Lum- 
brici. 
Ascaris Lumbricoides. 



Thread Worms. 

Oxyuris Vermicularis. 



Trichinosis. 

(Trichinae in the blood 
and muscular sys- 
tem.) 
Trichina Spiralis. 



Pathognomonic: Echinococci or micro- 
scopic hydatids in the contained fluid, which 
may safely be drawn by aspiration. 

_ Symptoms of intestinal irritation. Capri- 
cious appetite. Pain of a gnawing or griping 
character. Tenderness on deep pressure over 
the abdomen. Tumid condition of the belly, 
Alternate constipation and diarrhoea. The 
tongue pale, flabby, indented by the teeth, and 
often has a peculiar shiny appearance. Pupils 
generally dilated. Squinting, nervous twitch- 
ings, or even convulsions. Sleep is restless, 
with grating of the teeth and waking with 
sudden starts. Fever may appear, often of a 
remittent type (worm fever, verminal fever). 

Pathognomonic: Worms found in alvine 
evacuations. 

Violent itching and irritation at the anus 
and vagina, increased at night. Tendency to 
strain. Itching at the nose. Leucorrhcea. 

Pathognomonic : Worms found upon ex- 
amining the parts, also seen in patient's bed 
and his underclothing. 

First Stage: Gastro-intestinal disturb- 
ances; thirst; loss of appetite; nausea; col- 
icky pain in the abdomen; constipation or 
diarrhaea ; coated tongue ; feverishness. Sec- 
ond Stage: Swelling and stiffness of the 
muscles; muscular soreness ; cedema of the 
subcutaneous tissue; copious sweating; de- 
bility and increased fever ; dyspnoea ; hoarse- 
ness and loss of voice ; dropsy commencing 
in the eyelids and face, and proceeding to the 
extremities ; difficulty of motion and respira- 
tion. 

Pathognomonic: Presence of trichinae in 
the faeces, or in the muscular structure. 

The differential diagnosis from rheumatism 
is in the soreness being in the muscles and 
not the joints ; from typhoid fever in the un- 
usual pain and stiffness ; the early swelling, 
dropsy, etc. 



236 DIFFERENTIAL DIAGNOSIS. 



Trichinosis ( Continued). 



Trichinae do not colonize equally through- 
out a muscle, but in groups here and there. 
It is best, therefore, to dissect out a muscle 
lengthwise, in order to judge of their num- 
ber. 



The very large number of symptoms attributed to the presence of 
worms in the intestinal canal is the irritation they cause, implicating 
the general nervous system. This, occasionally, extends so far as to 
produce a "worm fever v " which in many respects resembles a mild re- 
mittent with unusually pronounced nervous symptoms. The tongue 
is pale and flabby, and often has a peculiar shiny appearance (Date). 
The pupils are generally dilated. Squinting sometimes occurs, and 
nervous twitchings of a choreic character. The fever is often high, 
with great heat of skin, and the cerebral manifestations being marked, 
may lead to the suspicion of hydrocephalus. From this it can be dis- 
tinguished by the more direct remissions; by the previous history, 
showing the primary symptoms to be referable to derangements of the 
alimentary canal ; by the less obstinate constipation ; and by the ex- 
pulsion of worms, after a dose of calomel or castor oil. 

This has also been confounded with tubercular disease. Here the 
most important diagnostic point is the temperature. This in tubercu- 
lar disease is always high ; but when the irritation is from worms it is 
either normal or but temporarily elevated above the normal standard. 
In trichinosis, however, there is usually a continued fever during the 
period of muscular invasion. 

Prof. Da Costa and others have succeeded, by extracting a piece of 
muscle from a patient's arm with a peculiar shaped trocar, in discover- 
ing living trichinae in the muscular tissue, and establishing the diag- 
nosis beyond question. 



CHAPTER V. 

DISEASES OF THE URINARY ORGANS. 

The Early Signs of Bright s Disease — Comparative Diagnosis of the 
Different Forms of Bright s Disease {Acute Parenchymatous Nephritis, 
Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Contrac- 
tion of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albuminoid 
or Amyloid Renal Degeneration, Parenchymatous Renal Degeneration) 
— Diabetes Mellitus and Glycosuria — Diabetes Insipidus arid Hydruria 
— Bile in the Urine — Urinary Calculi. 

General methods for the examination of the urine, and the chemical 
reagents and manipulations required in its analysis, are to be found in 
so many text-books and treatises that we may omit them here, and 
confine ourselves to the differential symptoms of some of the most 
prominent and frequent renal diseases. 

THE EARLY SIGNS OF BRIGHTS DISEASE. 

The early progress of Bright's disease is often remarkably insidious, 
and readily escapes recognition. Nor is it always to be detected by 
the familiar and easy plan of testing for albumen; for this substance is 
by no means invariably present in the urine, even in advanced and well 
marked cases. Fothergill justly observes that the progress of inter- 
stitial nephritis is often without the albuminous secretion for long 
periods. 

On the other hand, it has been abundantly shown that albumen is 
occasionally and transiently present in the urine of persons who pre- 
sent no traces of nephritis; who, in fact, may be in excellent health. 
(Albuminuria of adolescents.) 

ON -SOME FORMS OF ALBUMINURIA NOT DANGEROUS 

TO LIFE. 
The gravity of albuminuria as a symptom has been differently esti- 
mated at different times, but gradually it has become, in recent years, 

(237) 



238 DIFFERENTIAL DIAGNOSIS. 

to be known that albumen often appears in the urine, even in consider- 
able quantity and very persistently, in persons free from important or- 
ganic, malady. Indeed, it may be maintained that some patients with 
persistent albuminuria are yet eligible for life-insurance at little, if at 
all, above ordinary rates. 

It is, therefore, important to know the characteristic features of 
these non-dangerous albuminurias and in general the pathological im- 
port of this symptom in a given case. 

Dr. Grainger Stewart,* recognizes the following varieties : 1, par- 
oxysmal albuminuria; 2, dietetic albuminuria; 3, albuminuria from 
muscular exertion ; and, 4, simple persistent albuminuria; and illus- 
trates each with reports of cases which are markedly characteristic. 

The diagnostic features of paroxysmal albuminuria are the sudden 
appearance of more or less albumen in the urine with numerous casts, 
the process lasting only a short time and recurring at intervals with or 
without a perceptible exciting cause. The exciting cause, according 
to Dr. Stewart, is irritation of the kidneys from blood-changes. The 
treatment should be directed, on the one hand, to the avoidance or 
diminution of renal irritation, and, on the other, to the regulation of 
the hepatic function and of the chemical processes in the body. Hap- 
pily, the attacks are usually of brief duration, and he has never known 
them prove permanently injurious. 

Dietetic albuminuria is a variety which has long been more or less 
distinctly recognized. Some people suffer from it whenever they in- 
dulge in certain articles of diet. In some cases one kind of food, in 
others many 7 , require to be proscribed: cheese, pastry, and eggs are 
among the more common offenders. Of this group our present knowl- 
edge does not suffice to afford a satisfactory explanation. 

The cases of albuminuria following upon muscular exertion Dr. 
Stewart is disposed to attribute to a general change in vascular activity. 
The principal indications for their treatment are met by rest, judicious 
diet, and attention to the general health. Those remedies which act 
upon the muscular fibres of the vessels deserve trial. 

The features of simple persistent albuminuria are the constant pres- 
ence of albumen, usually in small quantity, unattended by tube-casts, 

* American Journal of the Medical Sciences, Jan., 1887. 



DISEASES OF THE URINARY ORGANS. 239 

diminution of urea, increased muscular tension, cardiac hypertrophy, 
or other consequence of renal malady, persisting for a period of months 
or years, and little influenced by diet or exercise. 

Dr. Stewart concludes his study with a consideration of the prog- 
nosis of these groups, placing special dependence upon the quantity of 
the urea, the presence or absence of tube-casts, and the condition of 
the pulse and heart. 

From the foregoing the necessity of determining the character 
of the form of renal disease becomes manifest. The presence of 
tube-casts has been urged as pathognomonic of renal hyperemia and 
inflammation.* These must be sought for with considerable care, as 
from the transparent character of some of them, and the fact that they 
do not form a sediment, they are readily overlooked. The direc- 
tions given for their search are that the urine to be examined is placed 
in a tall, conical glass; after three to six hours it is inspected; from 
the visible deposits, whether floating or sedimentary, with the pipette 
a quantity is taken sufficient to fill a concave slide or a shallow cell. 

This little pool is first searched with a four-tenths objective, and in 
a little time any cast or other microscopic object it contains is found. 
A more careful observation is made of the object thus found with the 
one-fifth. When the examination of deposits has been made in this 
way, the conical glass of urine should be set aside (a little chloral may 
be added, to prevent decomposition), and after twelve hours more the 
examination should be repeated. Of course, it will be remembered 
that the hyaline cast may be found when the condition of the kidney 
is only one of transient hypersemia. The character of cast is of con- 
siderable importance in prognosis. Tyson f has declared that per se 
he attaches little consequence to the presence of casts unless they are 
fatty or contain oil drops. 

We shall now proceed to classify the diagnostic points in the differ- 
entiation of the seven forms into which the varieties of Bright's dis- 
ease are now divided, premising that more than one form may exist in 
the same patient. (Nephritis is not a synonym for Bright's disease, 
since it may occur in only one kidney. — Da Costa.) 

* Dr. B. A. Segur, Proceedings of the Medical Society of Kings Co., 1878, p. 241. 
fProf. Jas. Tyson, Proceedings of Phila. County Medical Society, vol. iv., p. 133. 



240 



DIFFERENTIAL DIAGNOSIS. 

COMPARISON OF THE DIFFERENT 



. 


ACUTE DESQUAMATIVE 


CHRONIC TUBAL 


YELLOW FATTY 




NEPHRITIS. 


NEPHRITIS. 


KIDNEY. 


History. 


Sudden onset after 


Symptoms of more than 


Often follows alcohol- 




scarlet fever or ex- 


six weeks' duration. 


ism. 




posure to wet and 


Often history of acute 






cold; CEdema of the 


nephritis. Ur ae m i c 






face the sign first no- 


symptoms; abnor- 






ticed; headache, fe- 


mally low tempera- 






■ verishness, pain in 


ture. Serous inflam- 






the loins, gastric dis- 


mations. Cardiac 






turbance. 


hypertrophy. 




Appearance. 


Dropsical, more or less 


More or less oedema, 


Dropsy considera b 1 e 




swollen about the 


and general anasarca. 


and persistent ; re- 




face ; skin generally 


A pale, almost char- 


nal cachexia often 




dry. 


acteristic, waxy look. 


marked. 


Urine 


Scanty, smoke colored, 


Generally scanty, 


Scanty, pale, low spe- 




dark when acid, red 


though variable. 


cific gravity, with 




if alkalized. Highly 


Pale, albumen about 


abundant sediment 




albuminous. Speci- 


one-fourth, specific 


of oily casts and cells 




fic gravity high, 


gravity low, I.005- 


filled with oil. Al- 




1.025 -1.030. Red- 


1.015; white sedi- 


bumen abundant. 




dish brown sediment 


ment of hyaline and 






of epithelial, blood, 


epithelial casts. No 






and hyaline casts. 


blood casts. 




Prognosis. 


Recovery frequent. 
May lead to chronic 
tubal nephritis. 


Recovery not likely. 


Almost certainly fatal. 


Pathology. 


Kidneys enlarged, con- 


Kidney enlarged, cor- 


Kidneys enlarged, fat- 




' gested, vascular ; cor- 


tical substance in- 


ty, mottled, the tubes 




tical substance in- 


creased, ca p s u 1 e s 


full of fat and oil 




creased. Tubules 


easily separated. 


cells. 




dark and dense. 


"Large white kid. 
ney." 





DISEASES OF THE URINARY ORGANS. 
FORMS OF BRIGHT'S DISEASE. 



341 



SECONDARY CONTRAC- 
TION OF KIDNEY. 

Symptoms of more than 
a year's duration. 
Headache. Coma or 
convulsions. Cardiac 
hypertrophy. Epis- 
taxis. 



Generally some dropsy, 
but not very exten- 
sive. Face sallow. 



Scanty, pale, specific 
gravity about 1.015. 
Albumen moderate. 
Sediment of pale 
casts, dark granular, 
fatty cells, and waxy 
products. 



Generally fatal, but of 
slow progress. 



Kidneys contra c t e d, 
dense, capsule adher- 
ent; atrophy of the 
tubules. 



16 



INTERSTITIAL 

NEPHRITIS. 

RENAL CIRRHOSIS. 



Symptoms few and 
faint. Often the ar- 
thritic diathesis. Ex- 
posure to cold and 
fatigue. Sense of 
weariness. Frequent 
headache. Amauro- 
sis. Cardiac hyper- 
trophy. 

Little or no dropsy. 
Nerve implications, 
as paralysis, loss of 
sight or hearing, etc. 



Largely increased, pale; 
albumen trifling ; sed- 
iment little, of finely 
granular casts, or 
minute oil drops. 
Specific gravity low. 



With care, not immedi- 
ately dangerous, but 
predisposes to uraemic 
attacks from expos- 
ure. 

Kidneys at first en- 
larged, later con- 
tracted ; connective 
tissue increased ; cap- 
sule adherent, dimin- 
ished, and corru- 
gated. " Chronically 
contracted" kidney. 



ALBUMINOID OR AMY- 
LOID RENAL 
DEGENERATION. 



Antecedent syphi 1 i s, 
phthisis, or osseous 
disease and chronic 
suppuration. En- 
larged liver or spleen. 
Chronic diarrhoea. 



Dropsy generally 
amenable to treat- 
ment. Emaciation. 
Face sallow or pal- 
lid. Dyspnoea. 

Largely increased. 
(50-60 oz.) pale or 
golden; albumen 
considerable, perhaps 
one-half. Sp e c i fi c 
gravity 1.007-1.015; 
little or no sediment ; 
casts hyaline and 
waxy. 

Incurable, though the 
patient may live for 
years. 



Kidney enlarged, 
smooth, waxy look- 
ing. 



PARENCH YMA- 
TOUS RENAL 
DEC E N E R A- 
TION. 

Pregnancy 
diphtheria, or 
acute fever. 



Generally n o 
dropsy. 



Normal in 
amount. Al- 
bumen -j^ to 
\ bulk. 



Recovery 
quent. 



fre- 



Kidney en- 
larged, the 
parench y m a 
more or less 
hypertro- 
phied. 



242 DIFFERENTIAL DIAGNOSIS. 

The effort has also been made to call in the aid of the ophthalmo- 
scope. The presence of minute white exudations in the retina, prin- 
cipally around the maculae luteae, are believed to point to the presence 
of Bright's disease, and to be found in its early stages (retinitis albu- 
minurica). The appearance of the retina in these cases is characteris- 
tic. It consists in the grouping of small white spots, the outline of 
each being clearly defined ; they are invariably circular, of extremely 
small dimensions, and present the appearances of a pearl of an in- 
tensely bright color, and stand out from the retina in a marked man- 
ner. The grouping of the spots is symmetrical in each eye, and is 
generally in the form of a crescent. Often the urine will only yield 
signs of the minutest quantities of albumen — sometimes none at all ; 
but hyaline casts and these white spots may be detected by the pro- 
cesses here described. 

In the form of amyloid degeneration the difficulties of diagnosis are 
considerable, as not only has it been generally recognized that albu- 
men may be absent for considerable periods while the disease is 
steadily advancing, but it has been abundantly shown that it may never 
appear at all in fatal cases.* 

It seems, therefore, certain that we possess at present no sure diag- 
nostic sign of amyloM degeneration of the renal vessels ; that on the 
one hand, it is likely to be confounded with, or mistaken for, chronic 
parenchymatous nephritis asising under etiological conditions ; on the 
other, it runs a great risk of being altogether overlooked. But both 
of these evils may be avoided with a little care. Bartels points out 
that the differential diagnosis between amyloid disease and chronic 
parenchymatous nephritis depends upon the distinguishing characters 
of the urine, which, in the former, is clear, with little sediment and few 
casts, mostly hyaline, and scarcely ever blood-corpuscles ; in the latter 
it is always more or less turbid, with considerable sediment, is dirty 
colored, contains many casts of every variety, and not uncommonly 
blood-corpuscles. In those cases in which no albumen was present, 
there have been signs of amyloid disease in other organs ; and, in or- 
der to escape error, it will be well enough to know that the absence of 

* Lecorche, "Maladies des Reins," Paris, 1S75; LlTTEN, Berliner Klin. Wochenschrift. - 






DISEASES OF THE URINARY ORGANS. 243 

albumen from the urine does not exclude a slight degree of amyloid 
disease of the kidneys. 

Cystic kidney is not considered worthy of special remark, since or- 
dinary cysts are not to be recognized with any certainty during life, 
nor can they always be distinguished from the chronic varieties of 
Bright's Disease, in which they frequently are developed (Da Costa). 

DIABETES MELLITUS AND GLYCOSURIA. 

The presence of sugar in the urine is characteristic of both these 
conditions. The most convenient simple test is caustic potash 
(Moore's test), either in solution or small fragments. Heated with 
urine containing sugar, this substance immediately produces a more or 
less yellow or brown color, the intensity of which is in proportion to 
the quantity of sugar present, and a peculiar sweet smell (melassic 
acid). Picric acid solution with potassa and diabetic urine strikes a 
crimson color when heat is applied (Roberts). 

The test usually preferred is Trommer's or Fehling's, which de- 
pends upon the reduction of a salt of copper by the sugar. [The 
Fehling's test may be obtained in a solid form from Wyeth, of Phila- 
delphia, for the extemporaneous preparation of the solution.] Certain 
medicinal substances reduce copper from the test solution — as turpen- 
tine, chloroform, benzoic acid, salicylic acid, camphor, copaiba, cubebs 
— and if the patient is taking these, resort should be had to the fer- 
mentation test with compressed yeast or the polariscope. 

Apart from this test, the presence of sugar in the urine is revealed 
by many indications. We may often recognize it by grayish patches 
on clothing or linen, which are reduced to powder when scratched with 
the nail. Another circumstance indicating the sugary savor of the 
urine, especially in the country, is the great number of flies or ants 
that will be attracted around the vessel containing it. Pruritus vulvae 
is often caused by diabetic irritation. 

The presence of sugar once determined, it remains to decide whether 
it arises from simple glycosuria, which is a comparatively common and 
not dangerous condition, or from confirmed diabetes, which is more 
rare and a very perilous affection. This distinction has been insisted 
upon by M. Gerin Rozes, and most clinical teachers. The contrast- 
ing features of the two disorders may be presented as follows : — 



244 



DIFFERENTIAL DIAGNOSIS. 



DIABETES MELLITUS. 

Onset gradual; occurs at all ages, 
and without reference to known 
predisposing causes. 



The amount of sugar varies very 
little. Specific gravity of the urine 
high (1025-1030). 

The absence of saccharine food 
makes little or no change in the 
urine. 

Volumetric analysis by Fehling's 
method is easy. 

Polyuria, polyphagia, polydypsia, 
and impotence common and well 
marked. 

Nervous complications frequent. 

Treatment of little avail; result 
usually fatal. 



SIMPLE GLYCOSURIA. 

Onset sudden; more common in 
the aged; in persons consuming 
saccharine food; in the insane; in 
those taking chloral ; in the parox- 
ysms of ague ; after sudden excite- 
ment; blows on the head; cerebral 
affections.* 

The amount of sugar varies 
greatly from day to day (pathog- 
nomonic, Rozes). Specific gravity 
not far from normal. 

The withdrawal of saccharine 
food diminishes the sugar. 

Such analysis is obscure, owing 
to the quantity of creatinine and 
similar substances present. 

All these may be, and generally 
are, absent, or slightly marked. 

Rare. 

Treatment efficient; result usu- 
ally favorable. 



With the knowledge of the very fatal character of diabetes mellitus, 
a recognition of is earliest symptoms becomes of immense importance 
for treatment. Its invasion is seldom sudden, and at the very outset 
may be curable, which it rarely or ever is when once developed. 

Various nervous symptoms are among the earliest noted, and it is a 
wise rule in all nervous disorders of a doubtful character to examine 
the urine for sugar. Changes in the character of an individual, an ab- 
normal irritability of temper, insomnia, and extreme feeling of fatigue, 
disorders of vision, itching of the skin, pruritus of the genital organs, 
especially the vulva, and more or less protracted headache, are often 
premonitory symptoms. Intense and obstinate neuralgic pains, with- 

* In a clinical lecture by Da Costa, a case of cerebral syphilis is reported in which gly- 
cosuria occurred. — Philadelphia Medical Times, Jan. 22, 1887. 



DISEASES OF THE URINARY ORGANS. 245 

out obvious cause, especially in the feet and leg, should lead to the 
suspicion of diabetes. Recurrent boils and carbuncles are well known 
to accompany the diabetic condition. 

Genital impotence is one of the first signs of approaching diabetes ; 
and whenever individuals are met with who, previously virile, become 
weak and impotent without coinciding disease, especially of the spinal 
marrow, diabetes will usually be found to be the cause. Valuable in- 
formation is derivable from the mouth ; for besides the insatiable thirst 
and dry mouth, some patients complain of a disagreeable taste, which 
is sometimes acrid, and at others faint, or bitter, or sugary ; and it is 
this perverted taste which contributes to maintain the thirst. 

The mouth frequently exhibits an aphthous condition, while the 
edges and tip, and even the whole surface of the tongue, may present 
a red aspect, as if the aphthae had been removed. The gums, also, 
are often softened, fungous or bleeding; while in some the teeth be- 
come loose, or fall out without being decayed, and in others become 
carious. The breath is frequently of a bad, acid smell, and the saliva, 
in its reaction, is acid instead of neutral. Another fact which has 
sometimes led to the diagnosis is the existence of intertrigo at the 
commissure of the lips. This intertrigo labialis is not exclusively con- 
nected with diabetes, but when met with should always lead to an ex- 
amination of the urine. 

With regard to the digestive organs, boulimia on the one hand, and 
a complete repugnance for food on the other, with dyspepsia, should 
lead us to suspect diabetes. The unusual thirst of diabetics prompts 
them to drink large quantities of water at night, and such a habit 
should suggest strict inquiry for other symptoms. As a general rule 
it may be said that whenever there is muscular debility, emaciation 
and anaemia, without discoverable local cause, the urine should be 
examined, and will almost always be found to contain either sugar or 
albumen. 

The prognosis in a case of Diabetes Mellitus improves with the age 
of the patient; occurring in elderly persons, with ordinary care, it does 
not appear to shorten life (Da Costa). 



246 DIFFERENTIAL DIAGNOSIS. 

DIABETES INSIPIDUS (POLYURIA) AND HYDRURIA. 

The habitual discharge of an excessive amount of urine of low 
specific gravity, and containing neither albumen nor sugar, if accom- 
panied with progressive emaciation, excessive thirst, and loss of vital 
power, constitutes diabetes insipidus ; but under various conditions ex- 
cessive diuresis may be temporarily present, as in hysteria and other 
oerebro-spinal and nervous affections, without serious general symp- 
toms, and constitute the condition of hydruria. The distinction be- 
tween the two can be made by noting the coincident disease in the 
latter form, the slight direct impairment of the general health, the 
varying amount of urine voided, and by the fact that the quantity, al- 
though large, never attains those extraordinary measures — thirty to 
fifty pints daily — which marked cases of diabetes insipidus present. A 
large amount of urine is discharged by patients with amyloid degener- 
ation of the kidney. 

BILE IN URINE. 
The significance of bile in urine is the same as that of jaundice, as 
it indicates the presence of bile in the blood (see page 229). The tests 
are those for the bile pigment and those for the biliary salts. The 
color test usually employed is that of Gmelin ; a few drops of urine 
are placed upon a white plate and nitric acid dropped at its side; i 
bile pigment be present a play of colors, from grass-green to red, is 
produced. The same may be obtained by adding sulphuric acid to 
urine in a test-tube, and dropping in a crystal of potassium nitrate. 
The tests for the biliary salts are so complicated that they are entirely 
unreliable, as generally applied. For cautions and directions for their 
use the reader is referred to Neubauer and Vogel's " Chemistry of 
the Urine." 

REMARKS ON URINE TESTING. 
Physical Characters. — In the first place, in order to have any scien- 
tific value, the examination must be made of a specimen of the whole 
urine, or complete amount discharged in the twenty-four hours. The 
bladder should be emptied at a certain hour, and all the urine (includ- 
ing that passed at the same hour the following day) collected and meas- 






DISEASES OF THE URINARY ORGANS. 247 

ured. In summer time the receiver should be kept in a cool place 
during this time, in order to prevent bacterial development and decom- 
position. In cases requiring extraordinary care, the urine obtained at 
each act of micturition may be kept by itself. This not only will give 
information as to the frequency of the act and the working capacity of 
the bladder, but will also enable a separate analysis to be made of the 
urina sanguinis, potiis, and cibi, the importance of which is insisted 
upon by Golding Bird and others, and which we cannot dwell upon. 
The odor, color, consistency, and chemical composition of the urine 
are affected by the diet. It is well known that albumen and sugar in 
some cases are only present after meals, and that the prognosis of such 
a case is better than when either continues during fasting. The reac- 
tion and specific gravity are also different in the urine passed before 
from that passed after eating. 

With regard to the determination of the specific gravity, the cus- 
tomary method yields information of no real value. In the first place, 
the urinometers used in hospitals and by physicians are often unre- 
liable; and in the second place, the object of the examination is not 
attainable by the usual procedure. The specific gravity is desired only 
in order to determine the amount of solids present in solution in the 
urine, from which to discover whether the excretion by the kidneys of 
nitrogeneous waste is sufficient, in excess, or diminished. This can 
only be determined by an examination of a specimen of the mixed 
urine of the entire twenty-four hours. If carefully observed with a 
correct urinometer (such as Squibb's), or, more carefully still, with the 
picnometer and balance, the approximate amount can be readily deter- 
mined. (By multiplying the last two figures by Haeser's co-efficient 
2.33, which gives the proportion of urea in 1,000 parts of urine, from 
which the entire daily quantity discharged may be estimated.) Before 
taking the specific gravity the urine should be boiled and filtered while 
hot; if there is a deposit of urates on cooling, an equal volume of dis- 
tilled water may be added to the urine, and the proper correction made. 
The proportion of urea may be determined more accurately by the 
hypobromite process, with Greene's apparatus, or its recent modifica- 
tion by Marshall* 

* Zeitschrift fur Physiologische Chemie, Vol. xi., p. 179. 



248 DIFFERENTIAL DIAGNOSIS. 

The mere presence of albumen in a specimen of urine is of small 
importance when compared with a diminution of urea. Some years 
ago Dr. Wm. L. Richardson pointed out (in a communication to the 
American Gynaecological Society) that in pregnancy the existence of 
albuminuria may be practically ignored as long as the kidneys dis- 
charge the normal quantity of urea; when they fail, however, and the 
quantity is far below the normal, the patient is in danger of uraemic 
convulsions. 

The detection of albumen, however, may be useful in another direc- 
tion, since it furnishes valuable information indirectly by leading us 
to examine the urine for tube-casts. But just as albuminuria may 
exist without renal disease, so may tube-casts be present in the urine 
without indicating the presence of organic kidney affection. Neither 
albumen nor tube-casts, singly or in combination, will invariably deter- 
mine the existence of Bright's disease.* An exception to this state- 
ment, however, is necessary, in the case of fatty and lardaceous casts. 

Albuminuria may be a part of a general pyrexia (due to the effect of 
increased temperature upon the filtration of albumen ;f) and Grainger 
Stewart J has recently published a very interesting paper on some 
forms of albuminuria not dangerous to life, which he divides into four 
classes: (1) Paroxysmal albuminuria; (2) Dietetic albuminuria; (3) 
Albuminuria from muscular exertion; and (4) Simple persistent albu- 
minuria. To these, additions might yet be made without impairing 
the force of his statement that " some patients with persistent albu- 
minuria are yet eligible for life insurance at little, if at all, above the 
ordinary rates." . 

On Testing for Glucose. — In conclusion, there are several fallacies in 
the test for for glucose which are sometimes overlooked. Patients who 
are taking chloral, chloroform, benzoic or salicylic acid, turpentine, 
copaiba, cubebs, or camphor, and other medicinal substances, will fur- 

*Prof. James Tyson. Proceedings of the Philadelphia County Medical Society, Vol. iv., 
pp. 133, 134. 

f A Loewy. Auf die Einfluss der Temperatur auf die Filtration von Eiweiss-lSsungen 
durch Thierische Membranen. — Zeitschrift fur Phy siologische Chemie, Vol. ix., H. 9, 
1885. Also editorial Piiiladelphia Medical Times, Vol. xvi., p. 18. 

% The Americanjournal of the Medical Sciences, January ', 1887. 



DISEASES OF THE URINARY ORGANS. 249 

nish urine producing a deposit of the oxide of copper by Fehling's 
test. Indeed, the Fehling's solution itself should first be tested with 
some dilute normal urine in order to see that it is reliable, since it 
readily undergoes changes that lead it to spontaneously deposit the 
copper. A recent case, which occurred in Baltimore, is very instruc- 
tive. An applicant for life insurance was rejected by several companies 
on the ground that he had a high grade of diabetes mellitus. Upon 
applying the copper test, an abundant orange-colored precipitate was 
formed, beyond question. Dr. T. B. Brune, of Baltimore, found that 
the fermentation test and polariscope both failed to give evidence of 
the presence of sugar.* Prof. Tyson was called in consultation, and 
decided that the reducing substance was not glucose. The urine was 
subsequently tested by Prof. Wormley and Dr. Marshall at the Uni- 
versity of Pennsylvania, who believed the substance to be an acid not 
recognized heretofore. It has been suggested that this new reducing 
substance is oxaluric acid, which had been previously found . by 

SCHUNCK.f 

URINARY CALCULI. 
There are but three forms of calculi which are at all of common 
occurrence, and which are, therefore, likely to demand analysis. These 
are uric acid and its compounds \ oxalate of lime, and the mixed phos- 
phates. Calculi of xanthine and cystine are found, though very rarely. 

1. Uric acid calcidi are the most common. They are either red or 
some shade of red, and usually smooth, but may be tuberculated. 
They leave a mere trace of residue after ignition. 

2. Oxalate of lime calculi are frequently met with. They are gen- 
erally of a dark brown or dark gray color, and from their frequently 
tuberculated surface have been called mulberry calculi. They may, 
however, also be smooth. Considerable residue remains after ignition. 
The calculus is soluble in mineral acids without effervescence. 

3. Calculi of the mixed phosphates or fusible calculi are composed of 
the phosphate of lime and of the triple phosphate of ammonia and 
magnesia. They form the external layer of many calculi of different 

* A reducing substance in urine resembling glucose.— Boston Medical and Surgical Jour- 
nal, Vol. cxv., p. 621. 

f Medical Register, Vol. i., p. 10. 



250 DIFFERENTIAL DIAGNOSIS. 

composition, and may form entire calculi, but very seldom form the 
nuclei of other calculi. They are white, exceeeingly brittle, fuse in the 
blow-pipe flame, and are soluble in acids, but insoluble in alkalies. 

Few calculi of large size are of the same composition throughout. 
Oxalate of lime is the most frequent nucleus ; uric acid may also serve 
as a nucleus, but phosphates, as stated, almost never. Small collec- 
tions of organic matter, as blood-clots, frequently form nuclei, and may 
often be recognized by the odor of ammonia on ignition. It is not un- 
common to find calculi made up of concentric layers of different com- 
position. 

TO DETERMINE THE COMPOSITION OF CALCULI.* 
Heat a portion of the powdered calculus to redness upon platinum 

foil. Note whether there is a residue. 

A. There is a fixed residue. To a portion of the original powder ap- 
ply the murexid test. (This is as follows: Dissolve a small portion 
of the powder in a drop of nitric acid on a porcelain plate, then care-' 
fully evaporate over a spirit lamp. When dry add a drop or two 
of liquor ammoniae, when, if uric acid is present, a beautiful purple 
color will appear where the ammonia spreads.) 

I. A purple color results ; uric acid is present. Observe whether a 
portion of the calculus melts on being heated. 

a. It melts and communicates — 

1. A strong yellow color to the flame of a spirit lamp; 
sodium urate. 

2. A violet color to the flame ; potassium urate. 

b. It does not melt. Dissolve the residue after ignition in a 
little dilute HC1, add ammonia until alkaline, and then am- 
monium carbonate solution. 

1. A white precipitate falls; calcium urate. 

2. No precipitate. Add some hydric sodic phosphate 
solution; a white crystalline precipitate falls ; magnesium 
urate. 

* The processes here given are taken, with slight alterations, from Thudichum's work on 
the Pathology of the Urine. 



DISEASES OF THE URINARY ORGANS. 25 I 

II. No purple color results. Observe whether a portion of the cal- 
culus melts on being heated strongly. 

a. It melts (fusible calculus). Treat the residue with acetic 
acid; it dissolves. Add to the solution ammonia in excess; 
a white crystalline precipitate falls ; ammonio-magnesium 
phosphate. In case the melteef residue is insoluble in acetic 
acid, treat with HC1 ; it dissolves. Add to the solution am- 
monia ; a white precipitate indicates calcium phosphate. 

b. It does not melt. Moisten the residue with water, and test 
its reaction with litmus paper; it is not alkaline. Treat 
with HC1; it dissolves without effervescence. Add to the 
solution ammonia in excess ; white precipitate ; calcium phos- 
phate. Treat the calculus with acetic acid ; it does not dis- 
solve. Treat the residue after heating with acetic acid ; it 
dissolves with effervescence; calcium oxalate. Treat the 
original calculus with acetic acid ; it dissolves with efferves- 
cence ; calcium carbonate. 

B. There is no fixed residue. Apply the murexid test (p. 250). 

I. A purple color is developed. 

a. Mix a portion of the powdered calculus with a little lime 
and moisten with a little water ; ammonia is evolved, and a 
red litmus paper suspended over the mass is turned blue ; 
ammonium urate. 

b. No ammonia ; uric acid. 

II. No purple color. 

a. But the nitric acid solution turns yellow as it is evaporated, 
and leaves a residue insoluble in potassium carbonate ; xan- 
thine. 

b. The nitric acid solution turns dark brown, and leaves a resi- 
due soluble in ammonia ; cystine. 



INDEX. 



Abdominal phthisis, 223. 
Abscess of liver, 233. 
Albuminuria, 237. 
Anemia, 75. 

pernicious, 73. 
Apoplexy, 84, 86. 
Arthritic dycrasia, 59. 
Asthma, 186. 

Bacilli, 77. 

comma, 78. 

method of detecting tubercle, 65. 
Bacillus lepra?, 77. 
Beri-beri, 139. 
Bilious remittent fever, 54. 
Blood examinations, 74. 
in malaria, 45, 46. 
Bowels, obstruction of, 223. 
Brain centres, 95, 98. 
Bright' s disease of kidney, 240. 
Bronchitis, 170, 176. 

capillary, 178. 

Cancer, nervous origin of, 130. 
Cerebral abscess, 137. 

disorders, 83. 

sclerosis, 94. 
Cheyne-Stokes respiration, 209. 
Croup, 151, 152. 



Dartrous dycrasia, 59. 
Diagnosis of fever, 17. 

eruptive fevers, 23. 

inflammatory fever, 23. 

variola, 24, 27-29. 

scarlatina, 24, 26-28. 

measles, 27, 29. 

typhoid and typhus, 31, ^. 

gastric fever, 36. 

typhoid and malarial fevers, 37, 

typhoid state, 41. 
malignant remittent, 43. 
malarial toxaemia, 45. 
cerebro-spinal fever, 47, 50. 
congestive, pernicious, malarial 
fever, 48. 

(253) 



Diagnosis of epidemic and sporadic cerebro- 
spinal meningitis, 49. 

typhus fever, 50. 

tubercular meningitis, 52. 

yellow fever and bilious re- 
mittent fever, 53. 

relapsing fever and typhoid, 
57, 76. 

rheumatic dyscrasia, 60. 

scrofulosis, tuberculosis and 
syphilis, 64. 

diseases likely to be confounded 
with rheumatism, 65, 67. 

inherited syphilis and rickets, 
70. 

gout and rheumatism, 72. 

rheumatoid arthritis, 73. 

pyaemia and septicaemia, 78. 

cerebral congestion and ane- 
mia, 83. 

cerebral apoplexy, 84. 

hemiplegia, 85. 

cerebral inflammation, forms 
of, 87. 

tubercular meningitis, 89. 

causes of headache, 91. 

hypertrophy and hydrocepha- 
lus, 93. 

brain lesions, 95, 98. 

spinal diseases, 101, 103, 106. 

cerebro-spinal affections, 108, 
114. 

paraplegia, 115. 

pseudo-hypertrophic paralysis, 
118. 

lead poisoning and hysteria, 
119. 

general paralysis of the insane, 
123. 

neurasthenia, 126. 

hysteria, 119, 132. 

epilepsy and hysteria, 133. 

tetanus, hysteria, strychnine- 
poisoning, and tetany, 134. 

neuralgia and myalgia, 136. 

cerebral abscess and neuralgia, 
137. 



254 



INDEX. 



Diagnosis of mania and melancholia, 142. 

diseases of the larynx, 146. 

croup and diphtheria, 151, 152. 

lungs, diseases of, 164. 

forms of phthisis, 164. 

incipient phthisis, 168. 

incipient phthisis and bronchi- 
tis, 171. , 

syphilitic phthisis, 175. 

pneumonia and pleurisy, 179, 
184. 

pleurisy and hydro thorax, 181. 

pneumonia and pulmonary ap- 
oplexy, 185. 

pneumothorax and pneumohy- 
drothorax, 187. 

emphysema, 189. 

pulmonary cancer and phthisis, 
191. 

heart diseases, 196. 

aortic disease, 200. 

dilated heart and effusion, 206. 

cardiac hypertrophy and dila- 
tation, 208. 

fatty heart, 218. 

gastralgia and gastric ulcer, 2 1 5 . 

gastric and cerebral vertigo, 2 1 7. 

gastric and cerebral vomiting, 
218. 

gastric cancer, ulcer and gastri 
tis, 220. 

indigestion and dyspepsia, 221. 

enteritis and dysentery, 225. 

diseases of the liver, 226, 231. 

diseases of urinary organs, 237. 

acute desquamative nephritis, 
chronic tubal nephritis and 
fatty kidney, etc., 240. 

diabetes mellitus and glyco- 
suria, 243. 

polyuria and hydruria, 245. 

urinary calculi, 249. 
Diphtheria, 151, 152. 
Diseases, local, 81. 

of blood, 59. 

of circulatory apparatus, 192. 
of digestive organs, 2X1, 
Dobell's Aphorisms, 199. 
Drunkenness, 84. 
Dyscrasia, 59. 
Dyspepsia, 212, 292. 

Ehrlich's method of staining, 65. 
Embolism, 86. 
Emphysema, 189. 
Epilepsy, 133. 



Exanthemata, 23. 

Fatty heart, 208, 
Fever, 17. 

cerebro-spinal, 47, 48. 

eruptive, 23. 

essential, 22. 

gastric, 36. 

inflammatory, 22. 

malarial, 42, 44. 

relapsing, 56, 76. 

remittent, 43. 

remitto-typhus, 40. 

typho malarial, 39, 40. 

typhoid, 31, 32, 40, 57. 

typhus, S3- 

yellow, 53. 



Gastralgia, 215. 
Gastric fever, 36. 
General paralysis, 108, 
Gout, 72. 



20, 123. 



Headache, 91. 

Hemacytometer, Hayem's, 74. 

Hemiplegia, 85. 

" Hutchinson" teeth, 70. 

Hydrocephalus, 93. 

Hysteria, 119. 

Hysterical temperature, 23. 

Hystero-epilepsy, 133. 

Idiopathic fever, 22. 
Impaludism, 42. 
Infantile cerebral paralysis, IOO. 
Intestinal worms, 234. 
Insanity, 140. 

Jaundice, 227, 229. 

Kakke, 139. 

Larynx, diseases of, 145. 

Lead poisoning, 119. 

Leptomeningitis, 87. 

Leukaemia, 73. 

Localization of brain disease, 95. 

Locomotor ataxia, 68, 108, 114, 123. 

Liver, diseases of, 226. 

Lungs, diseases of, 154. 

Mania, 142. 
Melancholia, 142. 
Mental diseases, 143. 
Micrococcus erysipelatosus, 77. 
xanthogenicus, 77. 



INDEX. 



255 



Milk leg, 67. 
Multiple neuritis, 138. 
Myalgia, 67, 136. 
Myelitis, 106, 115. 

Neuralgia, 68, 135, 137. 

Neurasthenia, 126. 

Neuroses due to eye disease, 130. 

Ophthalmoscope, 89. 

Paraplegia, 115. 
Pericarditis, 205. 
Phthisis, abdominal, 223. 

pulmonalis, 164. 

syphilitic, 175. 
Plasmodium malaria, 46. 
Pneumothorax, 187. 
Pneumonia, 179, 185. 
Pseudo-hypertrophic paralysis, I] 
Pulmonary cancer, 190. 
Pyaemia 67, 78. 
Pyrexia, 17. 

Rashes, 24. 
Rheumatic gout, 73. 
Rheumatism, 65, 67. 
Rickets, 70. 

Scrofula, 61. 
Sclerosis of cord, 108. 
Septicaemia, 78. 
Spinal diseases, 101, 102. 
irritation, 125. 



Spirillum, 76. 
Stomach diseases, 219. 
Streptococcus, 76. 
Strumous dyscrasia, 61. 
Suppuration, cause of, 76. 
Syphilis, inherited, 64. 

Teeth in scrofula, 61. 

in rheumatism, 69. 
Temperature, 17. 
Tendon reflex, 112. 
Tetanus, 134. 
Tetany, 134. 

Thermometer, clinical, 17. 
Thermometry, 18. 
Thrombosis, 86. 
Tonsillitis, 153. 
Toxemia, malarial, 45. 
Trichina;, 235, 236. 
Tuberculous dyscrasia, 63. 
Tubercular meningitis, 52. 
Typhoid fever, 31, 32, 36,88. 

forms of, 36. 

state, 41. 
Typhus fever, 33, 50. 

Uremia, 83. 

Urinary examinations, 243. 

Urine, tests for sugar in, 243. 

Vertigo, 217. 
Vomiting, 217. 

Yellow fever, 53. 



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